Medicare Attorney

You are sick and go to the hospital.  You make it past the emergency room and are in a bed being treated by doctors and nurses.  You are receiving medical tests and hospital food. But have you been admitted or are you held and under observation?  The difference in the designation could be the difference in insurance covering the stay, what gets paid for and if you are eligible for Medicare coverage of rehabilitation services.  The kicker is you may never know until you get the bill! As a Medicare Attorney, I wanted to share a few of the points.

Observation v. Inpatient:

Observation status – which usually lasts 24-48 hours – is used to determine if a patent can be sent home or needs to be admitted.  Observation status includes all medically necessary and reasonable services including assessments, monitoring, tests and some procedures.  The observation status is determined by the doctor and is based upon guidelines set by Medicare or your insurance company.

Moving you from observation to inpatient status happens when your condition worsens.  You may not know or be told when your status changes.

So how can status affect the cost and coverage of treatment?

There are services – including x-rays, prescriptions and lab tests – that Medicare won’t cover if you are in observation status.  If you have private insurance, the co-pays could be higher for observation status tests than inpatient status tests.

Medicare will pay for inpatient care when you are expected to need 2 or more nights in the hospital.  This is their ‘two midnight’ rule. Further, Medicare will only cover nursing home for patients who have had a 3 day inpatient stay — the “three day stay rule.”  So if you were considered to be in observation only for a period of your time in the hospital you could fail to meet the two midnight or three day stay rule and be denied coverage from Medicare.  This denial could be costly if you require a nursing home stay after your time in the hospital, but due to your status, you were not considered to be an inpatient.

Since 2017, hospitals have been required to tell the patient of their status if they have been under observation for 24 hours. The social worker, case manager and financial office staff are required to inform you of your status under this Medicare Outpatient Observation Notice (MOON).  However, you need to be proactive and protect yourself.

You can:  1) ask your status, 2) ask the doctor to help you move to inpatient status, 3) if the hospital insists on observation status ask for the determination in writing, 4) don’t wait until your stay is over to address the status issue.

Contact a Medicare Attorney

Make sure that you are informed and protecting your rights as a patient.  This could save you hundreds or thousands in medical expenses.  If it is too late and you’ve already received the bill, reach out to us for legal assistance.

Excerpted from the Cleveland Plain Dealer Metro Section November 10, 2019.