“It all began when (…)” is a phrase we often use to explain the how and why of our present circumstances. If the “blank” was a medical crisis, such as a stroke, a fall or a heart attack, our path has taken an unexpected turn.
Many accidental safaris begin in a hospital emergency room.
Our sudden arrival sets into motion a series of rapid-fire actions and decisions that can mean the difference between life and death.
Importantly, some of these decisions can also save or cost us thousands of dollars.
Inside the emergency room, the physician will order the tests he/she feels is necessary to determine or confirm our condition.
If the tests indicate a serious problem, we will be admitted to the hospital as a “patient” for treatment.
If the test results are negative, we will be sent home.
What happens when the test results are inconclusive, but suggest that there may be an underlying undiagnosed issue?
If the hospital has sent us home and we collapse soon afterward from that “unknown something connected to the test that showed a little something was going on,” the hospital could be liable for not taking additional measures to avert the ensuing sirens and flashing lights.
Test results with “gray areas” present a serious quandary for hospitals, which must maintain a balance between compassionate care and financial stability.
To admit us as a “patient,” they must be able to check enough of the required boxes on the Admittance Form to satisfy Medicare’s admission requirements.
(Medicare is the primary health insurance for most Americans over the age of 65 or who have been on Social Security Disability for more than two years.)
Medicare controls how much the hospital gets paid for the services it provides and the sad reality is that hospitals must consider that Medicare might not pay and, even worse, that a Medicare audit could suggest that the hospital is guilty of Medicare fraud.
Faced with this conundrum, the safest option for the hospital is to place us in a hospital room, “under observation.”
Sadly, this will NOT be the best option for us! Whether we are admitted as a “patient” or placed in a room “under observation” will determine who will pay for our future treatment. If we are admitted to the hospital as a “patient” for three full days, and are subsequently moved to a rehabilitation facility, Medicare will pay 100 percent of the cost of the first 20 days of rehab, where costs can easily exceed $500 per day.
Medicare will also pay all but the first $157 per day for the following 80 days in rehab (also, most Medicare supplemental health insurance plans will cover the first $157 per day if Medicare is paying the back end).
If, however, we are in the hospital “under observation” for those same three days and then move to a rehab center, Medicare will NOT pay for the costs of our rehabilitative care.
The hospital is required to inform us in writing that we are in the hospital “under observation” and not technically a “patient” based on a Medicare law passed in 2016.
An Aug. 6, 2016 New York Times article titled, “New Medicare Law to Notify Patients of Loophole in Nursing Home Coverage” featured the story of an 85-year-old woman who was placed in a hospital for six days of “observation” after a fall, followed by nearly five months in a nursing home for rehabilitation and skilled nursing care.
The total cost of rehab exceeded $40,000, but because she had never been formally admitted to the hospital as a “patient,” Medicare would not pay.
An Accidental Safari often begins in the emergency room, and the dangers there are as perilous as those in a jungle.
Let’s take the steps to prepare to meet whatever challenges may come around the next turn in the road.
— Richard Tizzano
