After spending four days at a local hospital being treated for a broken elbow and pelvis, 93-year-old Lois Frarie went to a nearby nursing home to build up her strength. Her family was later shocked to learn they would have to pay thousands of dollars out-of-pocket since two of the days she spent in the hospital were considered "observation care" as an outpatient. Because she wasn't an inpatient for at least three consecutive days, she didn't qualify for Medicare's nursing home coverage.
"The distinction between inpatient or outpatient can make a tremendous difference to what Medicare patients have to pay," says TSCL Executive Director, Shannon Benton. Inpatient stays are covered under Medicare Part A. Inpatients who are hospitalized for three days or more qualify for Medicare's limited nursing home stay coverage. Observation stays are considered outpatient services covered under Part B. Observation patients can have much higher copayments costs and sometimes get hit with huge bills for non-covered drugs.
The number of Medicare patients in observation stays has jumped 69% in the past five years, according to federal records. They are also staying in the hospital longer. Even though Medicare recommends that hospitals decide within 24 to 48 hours whether to admit or discharge patients, the number of observation stays exceeding 24 hours have nearly doubled.
Federal records and senior advocates indicate that many observation patients who call Medicare about the billing problem are told there is nothing that Medicare can do to help. Hospitals are not required to tell patients they are under observation. Patients only learn they were receiving observation services when the bill arrives. By then it's too late because hospitals and doctors are prohibited from reclassifying observation patients as inpatients once they've been discharged.
Medicare has recently issued a proposed rule that would require, with some exceptions, patients who stay in the hospital two days or less to be classified as observation patients, and those who stay longer to be admitted as an inpatient. But the rule does not require hospitals to tell patients when they are in observation status or allow them to appeal the decision before they leave. Medicare recommends patients who are in the hospital for "more than a few hours" to learn their status. TSCL believes that the rules unfairly burden Medicare patients and their families, and believes that patients have a right to know their observation status and to be given an opportunity to appeal the determination. To learn more, see the publication "Are You a Hospital Inpatient Or Outpatient, If You Have Medicare — Ask!" (CMS No. 11435).
Sources: "Advocates Head To Court To Overturn Medicare Rules For Observation Care," Susan Jaffee, Kaiser Health News and USA Today, May 3, 2013.