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Merrimack Valley

July 22, 2013

Inpatient or outpatient? Status could determine Medicare eligibility

Q: My husband was recently taken to the hospital after experiencing an episode of syncope and falling at home.

He spent several hours in the emergency room and was then moved up to a room for further evaluation. He spent three days in the hospital but the doctors were never able to determine what had caused him to pass out.

To make matters worse I was told he was not eligible for Medicare reimbursement in a rehabilitation facility because he had stayed in the hospital under the “observation” status. He was too weak and unsteady for me to take him home so we had to pay privately for a week of therapy at the rehabilitation unit. Could you explain how this happens?

A: The Inpatient versus Outpatient status was addressed in this column over a year ago, at that time it appeared few people were being impacted.

Recently SHINE Counselors and state representatives have been receiving complaints from consumers who have encountered this issue. The timeliness of your question will hopefully alert other individuals to what could conceivably happen and clarify the ramifications.

Inpatient status refers to a patient who is formally admitted to the hospital with a doctor’s order. Medicare Part A covers inpatient hospital services with a one-time deductible for all services provided. Medicare Part B covers most of the related doctor services during the hospitalization. A patient is responsible for the Part B deductible and 20% of the Medicare approved amount.

If the patient has a Medigap plan (supplement insurance) additional expenses would be covered. For those who have a Medicare Advantage Plan cost and coverage may vary.

A patient is considered an outpatient if receiving emergency department services, observation services, outpatient surgery, lab test or X-rays and the doctor has not written orders to admit you as an inpatient even if they spend the night in the facility.

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