EagleTribune.com, North Andover, MA

July 22, 2013

Inpatient or outpatient? Status could determine Medicare eligibility

Rosanne DiStefano
Elder Q&A

---- — 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.

Medicare Part B covers outpatient hospital services and the individual would be responsible for a co-payment for each outpatient service provided. The total copayment for all services combined may be more than the inpatient hospital deductible. Drugs administered in this setting in most instances would not be covered by Part B. If the patient has a Part D plan (Medicare prescription drug coverage) the medications may be covered.

The issue many individuals have been most concerned over is in regards to the payment for skilled care provided in a rehabilitation facility following discharge from the hospital. Medicare only covers the cost of this care when there is a 3 day “qualifying hospital stay”. Observation or outpatient status does not meet the guidelines for the 3 day requirement since officially the person was never admitted to the hospital.

Never assume just because an individual spends the night or even several nights in a hospital the person has been officially admitted. Ask immediately what the hospital status is...inpatient or outpatient? This not only impacts cost of services provided but also whether Medicare will cover the care received in a skilled nursing facility (SNF).

Patients and family members need to understand the importance of advocacy and should speak with the hospital’s utilization or discharge planning department if they believe an improper decision has been made.

For additional information or to schedule an appointment call 1-800-892-0890. Do you have a question? We encourage inquiries and comments from our readers. Direct correspondence to ro@esmv.org or Elder Services of the Merrimack Valley, Inc. 360 Merrimack Street B#5, Lawrence, MA 01843. Rosanne DiStefano is the Executive Director of Elder Services of the Merrimack Valley, Inc.