89 yo Mom admitted to Memory Care 4 months ago. In past month she has become agressive and over past two weeks bit a caregiver who had to get a tetanus shot and attacked others. Physically strong but mentally in Stage 6 dementia--probably Lewy Body. MC center required that she be sent to geriatric psych unit to get medications adjusted so that she could be managed. They tried hard to manage in other ways for prior 3 weeks. Mom was taken to local ER; UTI, CT scan, were negative, providing medical clearance to get to psych unit as required. There were no beds available for 2 days, that turned into 3 days. MC refused to take her back until treated because she had to be restrained. She was held "in observation" with one-on-one nurse due to her trying to hurt herself and others for 3 days. Family didn't know she was "not admitted as a patient" until second day. Medicare won't pay for "observation" and her supplemental insurance won't pay unless it is a Medicare approved service. Three days in ER/ICU will cost thousands. Is this the way it is supposed to work? I am trying to get the hospital to change the code and admit, but it is doubtful they will. Any advice?
My understanding is that they won't pay for post hospital rehabilitation if they are not admitted but, the hospital bill is covered.
I would verify that the information is correct with the billing office. I could have outdated information, it has been a couple of years since I had to deal with this situation.
"Remember, even if you stay overnight in a regular hospital bed, you might be an outpatient. Ask the doctor or hospital. You may get a Medicare Outpatient Observation Notice (MOON) that lets you know you’re an outpatient in a hospital or critical access hospital. You must get this notice if you're getting outpatient observation services for more than 24 hours.
The MOON will tell you why you’re an outpatient getting observation services, instead of an inpatient. It will also let you know how this may affect what you pay while in the hospital, and for care you get after leaving the hospital."
https://www.medicare.gov/what-medicare-covers/what-part-a-covers/inpatient-or-outpatient-hospital-status
I was in that situation when I had an emergency appendectomy. One of the ER physicians said I would have the operation and follow-up on an "observational status." I stated that I must be admitted b/c otherwise I could not pay for anything not covered by Medicare, and not only that, I would refuse to pay b/c for surgery, I felt admittance was required.
The ER doctor was unaware of those distinctions and I was admitted.
They are not going to sue her, unless she has a bank account worth emptying. Does she?
If she does, pay the bill. If not, the hospital will code it properly.
They probably just didn't have any room and couldn't just place her in a regular room due to her behavior.
You could check with the higher ups and tell them that there is no money and if they want to be paid they better turn it in to the Insurance Co Coded the right way to get paid.
This observation hell is a huge problem when you are caught up in it. A MC should have been able to advise you on each step. This is surely not the first time they have been in this position. Although, what are the options? Hire a nurse to watch her at your home or a hotel room? MC won’t keep her. Hospital won’t admit her. Psych hospital won’t accent her. Where does she go?
One of the issues to me is that consumers aren’t given clear guidelines on what the choices are or what something is going to cost.
Was there another psych unit she could have been taken to? A different ER? Did she even need an ER since they sent her there for specific tests? Was moms choice of testing location based on being the nearest to the MC in order to access Medicare to pay for the ride? 3 weeks they were dealing with this but more importantly she was dealing with it. It seems when choosing a MC we are also choosing a hospital etc.
Why wasn’t the UTI tested for right away? The other tests could have been done outpatient. Does your mom act out with you? My DH aunt, with dementia, doesn’t with me but can be ugly to bathers. So while I might not want to do certain things with her, I know that I could take her for tests or ask the tests be done onsite when possible.
Lately with my DH Aunt, I just look at it as this is what she saved for. At almost 95 it’s ok to spend it if it’s needed. We can’t always know everything in advance but we do need to ask all the “what if” questions we can think.
In a setting such as your moms, I would be thinking surely they know what’s best but I’ve learned a few times, not the case. They know what is expedient for them. After all, they aren’t going to be paying the bill.
Hospitals are not transparent. They already know or highly suspect that insurance isn’t going to pay when they elect observation. I would like to better understand their checklist when a psych patient walks in the door. Perhaps psych hospitals should have their own ERs? Perhaps they do, but maybe your moms MC doesn’t have a contract with them? So hard to know all these things on the spot.
I’m sorry for all the losses you and your mom have recently suffered. I hope they get her meds straight and she can be at peace.
As it is we still will be out $5-6 K, easily, with reaching our out of pocket and the 20% co pay. Considering they sent him home just as sick as when he went in, that really rankles....I am grateful we have good insurance, but still.
This is something I wrote to help my family when a loved one is sent to the hospital. Most of the time the 3-day (midnights) applies to Traditional Medicare, many Advantage Plans waive this requirement.
Know Your Rights!
Observation vs Inpatient
When the doctor tells you that they are going to admit your loved one to the hospital you need to ask “Are they being admitted as an inpatient or Observation?” If the answer is inpatient there is nothing else you need to do. If your loved one is being admitted under “Observation” you need to be aware of some potential problems.
Observation Status is paid by Medicare Part B, while inpatient status is paid by Medicare Part A. Individuals who are enrolled in Medicare Part A, but not Part B will be responsible for paying the entire hospital bill if they are listed as “Observation” status.
Since March 2017, federal law has required hospitals to provide both oral and written notification to patients that they are being admitted as an Observation status if they are being admitted for more than 24 hours and are not being admitted as an inpatient. This is called the “Medicare Outpatient Observation Notice” or MOON, and notice must be given to the patient within 36 hours of admission to the hospital.
· When an individual’s status is “Observation” they may be charged for services that Medicare would normally pay for such a copayment for each outpatient service they receive or 20% of the Medicare-approved amount for most doctor services after Part B deductible.
· In order to get Medicare to pay for rehab in a long-term care facility the individual must be listed as an inpatient for three (3) midnights. If your loved one’s status is “Observation” Medicare will NOT pay for their rehab; it will be an out-of-pocket expense.
What options do you have if your loved one is admitted under “Observation?”
1. If the individual is still in the hospital:
a. Ask the doctor to help change their status to inpatient.
b. Use Medicare’s “two-midnight rule.” (Not to be confused with the (3) three-midnight rule above). This states that if their doctor expects the individual to require hospital care for at least two midnights, the hospital should be able to admit the individual as an inpatient.
c. Consider other resources for care such as an inpatient rehabilitation hospital, home health care or, outpatient therapy. These do not require a three (3) day inpatient stay.
If the individual is no longer in the hospital: Medicare does not have an official method to appeal the Observation status at this time.
Note: This information applies to Traditional Medicare. Many of the Medicare Advantage Plans don’t require the “three midnights” to receive skilled care in a long-term care community. You need to check with your Advantage Plan to make sure you are covered in the event you are sent to the hospital.
All of a sudden she had help. And when PT wanted to test her she was not able to walk 3 feet WITH a walker. Things changed in a hurry.
Get on the phone, call her doctors, insist on speaking with the attending physician. Don't take "NO" or "when they have a few minutes" for an answer. They are supposed to be helping her. Get whom ever holds the Medical POA involved along with the hospital patient Advocate (there should be one involved).
Good luck and God Bless,