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Beacon of HOPE Wellness Committee: Observation status in the hospital – look out

May 10, 2017
By Caryl Regan, RN (Special to The Eagle) , Pine Island Eagle

If you stay in a hospital overnight or even two days, you may be considered an outpatient. According to Medicare, you are an "outpatient" if you are getting emergency department services, observation services, outpatient surgery, lab tests, X-rays or any other hospital services and the doctor has not written order to admit you to the hospital as an inpatient. The doctor has Medicare guidelines he/she must follow when admitting a patient.

Very simply, if not followed Medicare will not pay the hospital.

So, where is the difference and how do the charges add up? It has to do with whether or not the charges are applicable under Medicare Part A or Part B.

Medicare Part A (hospital insurance) covers inpatient hospital services. Generally, this means you pay a one-time deductible for all of your hospital services for the first 60 days you're in a hospital.

Medicare Part B (medical insurance) covers most of your doctor services when you're an inpatient. You pay 20 percent of the Medicare-approved amount for doctor services after paying the Part B deductible.

What do you pay as an outpatient?

Part B covers outpatient hospital services. Generally, this means you pay a co-pay for each individual outpatient hospital service. In other words, each individual lab, X-ray, CT scan, MRI, etc., has a cost to you. So your total co-payment for all outpatient services may be more than the inpatient deductible.

Prescription and over-the-counter drugs you get in an outpatient setting sometimes are considered "self administered drugs" and aren't covered by Part B. (Quoted from Department of Health and Human Services website).

There is more

Medicare has a rule that says you must have stayed in the hospital for three consecutive days before they will pay the cost of nursing home care. If your hospital stay is less than three consecutive days and you require nursing home services, depending on your insurance, the cost of the nursing home could be out of pocket expense.

The time you spent in the hospital under the observation status does not count towards the three-day Medicare rule. This means, for example, if you were admitted under observation for two days, you would have to spend an additional three days in the hospital as an inpatient before your nursing home services would be covered.

As you can imagine, the out-of-pocket expenses can quickly add up to thousands of dollars. I have personally heard stories of between $5,000 to $6,000 of out of pocket expenses.

So, what can you do? Find out your admission status before you agree to stay overnight in a hospital. Speak with the doctor. I have a friend who was able to get her status changed by speaking with her doctor. Have a frank discussion about why you need to be under observation. What is the doctor concerned about? What does he/she hope to see accomplished during the stay? Ask about alternatives.

It is always best if you have an informed advocate accompany you and stay with you in the emergency room or the hospital.

If you have a concern you would like us to address, please let us know at the Beacon of HOPE, call 239-283-5123. The Beacon of HOPE is at 5090 Doug Taylor Circle, St James City. The website is beaconofhopepineisland.com/

 
 

 

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