Congress and the President need to pay more attention to the home front and needs of its citizens. One example of matter needing attention is Medicare payment for hospital stays that are classified, sometimes up to a year or more after the fact, as "observation stays" rather than "inpatient" stays. Semantics that can be costly to people in need of care.
Medicare will only pay for nursing home care if a patient is admitted to the home at the recommendation of a doctor and only after three days stay in a hospital. However, the increasing use of "observation status" for hospital stays of up to even ten days is resulting in denial of reimbursement of care needs for Medicare patients.
One example of a situation is described in this article in the Boston Globe.
Harold Engler recently spent 10 days in a Boston teaching hospital, trying to snap back from complications after urgent hernia surgery. Nurses provided around-the-clock treatment, changing the 91-year-old’s catheter, for example, and pumping him with intravenous drugs for suspected pneumonia.
It all seemed like textbook hospital care to his wife, Sylvia. So she was shocked to learn that Beth Israel Deaconess Medical Center had never “admitted” her husband at all.
“Mrs. Engler, we have bad news for you. This was marked ‘medical observation,’ ” said a nurse at the nursing home where her husband was sent for rehabilitation. The hospital had decided Harold Engler was not sick enough to qualify as an official “inpatient.”
It is a striking example of just how impenetrable the US health care system can be for those who use it. Thousands of Medicare enrollees in Massachusetts and across the country are finding themselves caught in the same perplexing bind: Despite long hospital stays, they have been deemed observation patients or outpatients whose follow-up care is not covered. They also can face higher costs for the hospital stay itself when they are not officially admitted.Here's an example from Ohio:
Last September, Theresa McGarry fell in a parking lot and fractured her hip. She spent nine days at Fairview Hospital and then -- over her objections; she wanted to go home to her apartment in North Olmsted — she was whisked by ambulance to ManorCare for three weeks of rehab.The article explains why this is happening...Medicare rules (that may be unclear) and the hospital's desire to protect their own bottom line by not "admitting" patients who they may be unsure may qualify for reimbursement from Medicare as "inpatients."
Almost a year later, the 83-year-old lives with two reminders of that mishap -- a limp and the lawsuit ManorCare filed against her for $6,000.
Ordinarily, Medicare covers a senior’s care at a nursing home as long as it’s preceded by a three-night “in-patient” stay at a hospital. But Fairview never formally admitted McGarry. Instead, for nine nights running, Fairview listed her status as “observation.” That distinction stripped McGarry of her Medicare coverage for skilled nursing care.
Vincent Mor, who studies health policy at Brown University, says hospitals that push more patients into observation generally do so because of the risks to their own bottom line.Fortunately one Democrat in the Senate is paying attention and attempting a Congressional fix:
If a hospital admits a patient and a Medicare auditor later second-guesses the admission, Medicare can claw back its payments, Mor said. “If Medicare disallows the payments,” he said, “they can’t change their minds and say it’s observation status.”
There’s enough confusion around the issue that the inspector general says that last year Medicare may have tripped over its rules and improperly paid for 23,000-odd nursing home stays that didn’t have a qualifying hospital stay beforehand, even though patients were in the hospital at least three days. Roughly 2,000 others, like McGarry, were just plain out of luck. On average, they wound up paying about $10,000 apiece.
Those bills often come as a surprise to patients.
“Doctors don’t like it. Nursing homes don’t like it. The patients don’t like it,” Callow said of the Medicare observation rules. “It’s so rare you find that kind of consensus."The particulars of the bill and how you can support are outlined here:
Changing the rule, though, may take an act of Congress. U.S. Sen. Sherrod Brown, the Democrat representing Ohio, has introduced a bill that would require Medicare to count the observation time a patient spends in the hospital toward a qualifying hospital stay. That bill also proposes retroactively reimbursing observation patients whose nursing home care bills were denied.
“We don’t think it’s widespread,” Brown said, “but even if it was only two times, it’s too many.”
A similar bill is gaining sponsors in the House.
On March 14, Sen. Sherrod Brown (D-OH) introduced Improving Access to Medicare Coverage Act (S. 569), a bill that would specify that hospital stays under observation would count toward the 3-day hospitalization requirement for Medicare coverage of post-acute care. Patients that receive hospital care on "observation status" do not qualify for this benefit, even if their hospital stay lasts longer than 3 days.Here's the link for sending a message to your legislators to support Brown's bill.
The observation days problem affects residents and clients of all LeadingAge members, including residents of senior housing or home-based services clients who are hospitalized and released to nursing homes. They are all at risk of substantial out-of-pocket costs for post-acute care without this corrective legislation.
Please help us persuade Congress to solve this problem that affects so many Medicare beneficiaries and skilled nursing facilities. Contact your legislators and urge them to cosponsor the corrective legislation.
For yourself and that of seniors you know and love, please take this simple action to help fix a serious problem.