Court RCourt rules Medicare Beneficiaries Can Appeal Switch to Hospital Observation Status

Ed1937

This could save you some big bucks if they go to a nursing home. https://www.elderlawanswers.com/court-rules-medicare-beneficiaries-can-appeal-switch-to-hospital-observation-status-18678?  

Jo C.

Please Note:  When the link states, "Medicare covers nursing home stays for the first 20 days . . ."  That is NOT nursing home custodial care.

What this means is that IF the person has been an inpatient in a medical center for three 24 hour days and IF the person fits Medicare criteria for "skilled care" or "skilled care rehab," then the person is covered for the skilled care admission which is provided in a nursing home.

Skilled care can mean complex wound care or IV meds that still needs the skilled care of an RN but no longer at the acute hospital level; or it can mean the skilled care of Physical Therapy for other conditions such as post hip or post hip surgery, post stroke care, etc. 

It is also true that Medicare was forced to change their criteria from needing to show ongoing increase in a patient's abilities to maintaining the patient's usual function status.

Important when you or a LO is admitted to the acute hospital to ask right at the time of admission if the admission is on an inpatient or outpatient status.  Ask your physician to admit you as an inpatient unless the stay really is only for 24 hour observation.  I have heard Members here tell of instances where a LO was in the acute hospital for over a week and a half and was still under the category of outpatient and it is legal.

It is recommended that when in the hospital to check every day to ensure that one is still at an inpatient status; this is important as one's status can be changed in the midst of a hospitalization or even after a discharge.   Staying informed of this will keep you from having to go through a very trying time attempting to fight a negative decision which is not all that easy and not every outcome will be what would be hoped for.

Interesting to me, is that since hospitals are reimbursed by Medicare on a Diagnosis Related Group (DRG) basis, things have got dicey.  DRGs means there is one flat fee for an admission - BUT - the fee will be what is set for the principle diagnosis that actually caused the patient's admission to the hospital; not for what happens after the admission.  So; a person is admitted for say; diverticulitis; the DRG payment is set on that diagnosis - BUT while hospitalized, the person perhaps develops pneumonia, or other infection, or has a heart attack or develops another issue . . . the payment will still be for the principle diagnosis that caused the admission to the hospital, not the other conditions. 

If the cost of the patient's care is low, the hospital can pocket the money not spent under the DRG as profit; however, if the cost of care exceeds the payment of the DRG, it comes out of the hospitals pocket.  Not always good for the patients . . . see where this is going?

Hospitals got savvy very quickly and beefed up special departments staffed by licensed nurses to follow and review the patients and discharge them swiftly as can be.   They often go out sicker and quicker.  Some hospitals use their MD hospitalists in this with pressure to get 'em out and lower those bed days waaaaaay down.

So; CMS sees the patterns of patients being discharged so fast that they rebound back ito the hospital and then decides to penalize the hospitals for patient readmissions that happen within a certain amount of time.  It is costly for Medicare when this happens.  This means $$$$$$ losses for the hospitals and if egregious, more severe penalties.

Well; the federal government that just cannot seem to get it right, approves the hospitals to use the extended outpatient admission that can go for days and days and days . . . because if a patient is an OUTPATIENT, the hospitals are not penalized for outpatient status admissions which are really readmissions; only inpatient readmissions.

Wonder how political this was and where pressure was brought to bear to get this sanctioned as appropriate or were the powers that be just that stupid and unconscionable . . . do not know.

The beleagured patient is a moving target and not always for the best.  We have had Members here sharing that they had no idea their LO was an outpatient status even though written notice must be given - things can go astray - or perhaps they did not understand.  Anyway; their LO was transferred to Skilled Care rehab only to find out after the fact that their LO did not qualify for Skilled Care as they were not on an inpatient status for those three 24 hour days.  Medicare will not pay for that and the patient becomes financially responsible for the cost of care at the NH.  One Member had to pay the Skilled Care for ten days stay and it was thousands. 

Sad, bad, needs changing.

Quilting brings calm

I never understood the difference between observation and admitted until now. I thought that there was the ER and then there was admitted, or there was same day surgery.  I’m not old enough for Medicare yet and I am grateful for this information. 

Observation shouldn’t even be a legal thing. If someone needs to be ‘observed’, then it should be done as an inpatient.  

Joydean

JoC thanks for the education! Like QBC, I did not understand all of that. Thankfully my husband has only been in the hospital one time in the last couple of years. But it’s good to know and understand what is going on now. So thank you.