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Topic "observation status" Go to previous topic Go to next topic Go to higher level

By Mary556 On 2014.07.12 10:19
in case this may help someone else...

If your PWP is hospitalized for three midnights, it is a good idea to ask *before discharge* what their status is, whether they were formally admitted per doctor's order on the first day. If not, try to get it changed while the person is still hospitalized.

Because of Medicare penalties, many hospitals are using "observation status" (Not admitted) for the first 24-48 hours of the hospital stay. Even if you stay overnight in a regular hospital bed, you might be an outpatient.

If the person is discharged to a skilled nursing facility instead of being sent home, Medicare will deny coverage. The patient needs to be admitted for all three midnights to qualify. The individual would be required to pay the rehab facility out-of-pocket, hundreds of dollars per day.

The Center for Medicare Advocacy has helpful information if you should find yourself in this situation.

By carman96 On 2014.07.12 14:10
Thank you for posting. Who thinks about Medicare's arbitrary rules when their loved one is ill?
Good to know these things ahead of time.

By JulieB On 2014.07.12 15:55
Wow -- who would have known? Thank you for sharing this with us, Mary... xoxo

By Mary556 On 2014.07.15 09:42
a CMA attorney spoke with me. she said the appeal process will take more than a year. then there is only a slim chance that "observation status" would be reversed to "admission" lasting the actual length of the hospital stay. the Attorney's advice is not to spend a lot of time on this now. we should just focus on getting the best care for my mother. for my parents' sake, I will start an appeal as time allows. this situation is too unfair to them. they have worked so hard all their lives to provide for our family. but we have no expectation the large expense will ever be recovered.

By Mary556 On 2014.07.19 06:11
updating my previous note so that someone else will not be discouraged from making an appeal...

My mother's case manager at the Rehab facility spoke with us. She said that some of these appeals are being won, more than there were before.

When we submitted my parents' first private payment, we put a note with it that we are going to appeal Medicare denial of coverage based on the "observation status" technicality. Rehab case manager is submitting the bills and 50 pages of paperwork to Medicare as if we had already made the appeal and won. If there is a small chance that Medicare will pay (a year or more down the road), the bills would need to be sent this way from day one, before the patient is discharged.

This seems to differ from instructions in the CMA self-help guide linked above:
"Step 5... To start the appeal, ask the nursing home to submit a “demand bill” to Medicare for your entire stay. You can make this request after you leave the nursing home." Maybe this is an additional step in addition to their ongoing billing to Medicare?

All of this is confusing, especially at a time when our attention is rightly focused on the well-being of our loved one.

By moonswife On 2014.07.19 07:22
Mary, thank you for the original post, and even more for the updates. You already have your hands full, it seems, and to keep our community advised is sincerely kind.

By Mary556 On 2014.07.20 17:24
Thank you for your kind words of encouragement, moonswife. There are many good people at this Forum who continuously support one another and I wish to be here in that spirit. You all have been so helpful to me.
I hope that telling about our unfortunate Medicare experience (and what we discover as we go along) may someday help another family who gets hit with this. It has helped me to vent anyway.

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