Benefit Bulletin: December 2014

Benefit Bulletin: December 2014

Why You Should Beware When The Doctor Wants To Hold You For "Observation"

Most people who spend the night in the hospital would say they have been an inpatient. But over the past six years, rapidly growing numbers of Medicare beneficiaries have learned that they were never admitted as an inpatient — even though they have stayed in a hospital bed, received treatment, diagnostic tests, and drugs.

Instead they learned they received observation care, which is considered an outpatient service, and is billed under Medicare Part B. With that designation, patients can have higher out-of-pocket costs even though they may have the very same health problems as people admitted as inpatients.

A study by the Health Care Cost Institute found that people receiving observation and other outpatient services in the hospital paid four times more out-of-pocket than inpatients in 2012— an average of $47 per inpatient versus $199 for outpatients. Under Medicare, outpatients usually have co-payments or co-insurance for each service from doctors, test, prescription drug, and other hospital services.

Worst of all, patients don't qualify for Medicare coverage of follow-up nursing home care, because Medicare requires three consecutive days in the hospital as an "inpatient." That leaves the patient and their families on their own to figure out how to pay nursing home bills, or to go without.

The number of observation patients has exploded 88 percent over the past six years, according to the Medicare Payment Advisory Commission. Medicare has tightened rules for hospital admissions, and usually won't pay for admitted patients who should have been designated as observation status. Consequently, hospitals have increased their share of observation patients. But the rule is not the same for people's private insurance like Medicare Advantage. Most Medicare Advantage plans don't require their enrollees to have a three-day hospital admission in order to receive nursing home coverage, according to an analysis by Avalere Health research firm.

TSCL believes the increased use of observation stays is denying Medicare beneficiaries access to medically necessary skilled nursing care. All days spent in a hospital should count toward Medicare's three-day hospital stay requirement. TSCL supports the Improving Access to Medicare Coverage Act (H.R. 1179) introduced by Representatives Joseph Courtney (CT-2) and Tom Latham (IA-3), and (S. 569) introduced by Senators Sherrod Brown, (OH) and Susan Collins (ME). The legislation would deem time an individual spends under observation status eligible towards satisfying Medicare's three-day requirement.