Big bills for uncovered charges are surprising some seniors after some hospital stays that aren’t considered inpatient services by Medicare. The problem occurs when the hospital classifies your stay as “observation” which is billed as outpatient care under Part B, rather than inpatient care which is billed under Part A. Your physician may order your admission as an inpatient, but in some cases the hospital later reverses the status retroactively. Whether you are an inpatient or an outpatient is extremely important, though, because it will determine how much you pay out-of-pocket, especially if you later need nursing home care.
Recently a group of Medicare patients and their families sued the Obama Administration, saying they were deprived of coverage because the policy allows hospitals to avoid admitting seniors with chronic ailments as inpatients. The plaintiffs charged that the observation services policy, which is intended to apply to short stays of no more than 24 to 48 hours, is instead being used to keep Medicare patients on outpatient status for longer stays, including some lasting up to a week. As a result, the seniors incurred medical charges as high as $30,000 for skilled nursing care, drugs and other costs that Medicare Part B does not cover. Inpatient stays are covered under Medicare Part A, and all of $1,156 deductible and most, if not all, of the co-insurance is covered by Medigap supplements.
Medicare Advantage plans have somewhat different costs. If the stay is considered observation care, however, that is covered under Medicare Part B, which means you will have a copayment for each individual outpatient hospital service. In addition, Part B doesn’t cover most prescription drugs that are received in an outpatient setting. Perhaps even more importantly, the lack of inpatient status also disqualifies you from receiving Medicare-covered care in a skilled nursing facility or nursing home.
To qualify for Medicare coverage, beneficiaries must be an inpatient for at least 3 days in a row, not counting the day of discharge. What you can do: If admitted to a hospital, it’s highly important that you, or your designated caregiver, find out immediately whether you are being admitted to the hospital as an inpatient or an outpatient. Even if you are admitted as an inpatient, the hospital can sometimes switch you to observation (and outpatient) status, but the hospital is required to notify you while you are still a patient. Should this happen to you, ask your caregiver to take steps to have the decision reversed while you are still a patient.
Usually, your doctor’s order is necessary. Before you need emergency care, put a plan into place, including someone to help take care of you should you become seriously ill. Often, doctors will order observation care when you are too sick to safely go home from the emergency room. Although this can still occur even with the best-laid plan, you may be able to reduce the length of an observation stay if you have someone who will take care of you once you are released. If you learn that your patient status was changed after your admission as an inpatient you have a right to appeal decisions about healthcare payment, coverage of services and prescription drug coverage.
For more information see the Medicare publication, “Are You a Hospital Inpatient or Outpatient?” CMS Product No. 11435. Get a copy online at www.Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).
Sources: “Medicare Beneficiaries Sue US Over Hospital Stays,” David Morgan, Reuters, November 3, 2011.