Not all stays in a hospital by Medicare patients are equal under the morass of regulations established through the years by this government bureaucracy.
In fact, a patient can be treated, assigned a room, spend a night or two and never be classified as “admitted.”
Why does this matter?
If a Medicare patient does not spend at least three full days and nights as an “admitted” patient and then is sent to a nursing home for additional care, Medicare doesn’t pay for that care.
I read “Medicare &You, 2008,” sent to me by my government in January. Page 13 explaining Medicare-covered services in hospitals neglects to mention that detail.
Sadly, as many Medicare patients learn, being treated “under observation” in a hospital is covered by our Medicare B plan rather than Medicare A, and that changes the rules of pay.
Such was the case with Donna Kuper’s 90-year-old mother who fell one night in the laundry room of her retirement center. Her family was notified and they took her to her physician for a complete checkup and several tests the following day.
“The next day Mom was still stiff and sore,” Kuper said. “We checked in on her every day, but as the week went on she did not improve.” Six days after her fall, severe back pain and muscle spasms in the night resulted in a trip to the hospital.
She was treated for her excruciating back pain and for injuries to her toes. There were X-rays that showed several old compression fractures in her back, Kuper said. “One spot could have been more recent.”
After two and a half days in the hospital, she was discharged and transported to a skilled nursing care facility for rehabilitation therapy.
They were not told, Kuper said, that her stay was “under observation,” so Medicare declined to cover nursing home care.
During the hospital discharge process, Kuper said, they were led to believe Medicare might not pay unless they signed all the release forms immediately. That had set off alarms. The realization that her mother would have to pay for the nursing home care came later.
After talking with Kuper, I went to an expert on how the Medicare process works in a hospital.
We did not discuss Kuper’s mother’s case.
Instead, I asked Norm McFarland, manager of the Care Management Department at Providence Health System in Everett, to explain the difference between “admitted” and “under observation” when a patient is being cared for in the hospital.
McFarland offered some history to frame the current situation. A dozen years ago as Congress explored ways to cut Medicare’s burgeoning costs (something they do on a regular basis), a decision was made to significantly reduce the budget for care in a skilled nursing facility following a hospital stay.
Smart folks, our politicians.
They created two versions of hospital stays: “admitted” and “under observation.” With these classifications came detailed forms for hospital personnel and physicians to complete that were to determine the seriousness of a patient’s condition to allow them to be “admitted” for “acute care.”
Patients who come in with conditions that can be treated in 24 to 48 hours such as nausea, vomiting, stomach pain, kidney stones, fever, back pain and even some types of chest pain will usually find themselves “under observation.”
This means, McFarland explained, a person needs to be in a hospital setting so their condition can be observed and tests run while physician and staff members diagnose the problem and form a plan of treatment.
To be “admitted” a patient must be in need of what Medicare specifies as “acute care” and there is a multitude of categories with even more criteria to reach that point. The book provided on this subject to the hospital by Medicare contains more than 400 pages of finite detail.
There are instances when a patient comes in “under observation,” but the severity of the illness and intensity of services required change their status to “admitted,” McFarland said.
To help patients understand this complex process, Providence prepared a brochure in January that is now given to all Medicare patients explaining what it means to be “under observation” versus “admitted.”
A patient who does not meet that “acute” status, like Kuper’s mother, may still need additional physical or occupational therapy in order to return home and resume a normal routine.
In that instance, a safe discharge plan will include the recommendation that the patient go to a skilled nursing facility or receive skilled nursing care in their home until they are fully recovered.
And while Medicare will not cover that cost if the patient was “under observation,” Medicare does cover home health services in many cases. Supplemental insurance may also help with these expenses.
For Kuper’s mom, the best choice for additional recovery help was a skilled nursing care facility. They assumed if Medicare wouldn’t come through, surely the long-term care insurance she’d been paying for through the years would take care of the bill.
The policy’s fine print told a different story. Her long-term-care insurance does not become effective until after a 90-day stay under Medicare A coverage.
This is not always the case, but if you have that insurance it’s worth checking on.
Kuper’s mother has recovered and returned to her comfortable apartment in an Everett retirement community.
The problem of Medicare’s inefficient systems and escalating costs remains. Change must come soon or there won’t even be enough money left to pay for the paper this monolith spews forth.
Now that would be a shame.
Linda Bryant Smith writes about life as a senior citizen and the issues that concern, annoy and often irritate the heck out of her now that she lives in a world where nothing is ever truly fixed but her income. You can e-mail her at ljbryantsmith@yahoo.com.
Talk to us
> Give us your news tips.
> Send us a letter to the editor.
> More Herald contact information.
