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    hospital observation status

    this is what the social worker at hospital gave me when i questioned my colonoscopy prep in hospital.





    #2
    Thank you for posting this.

    Comment


      #3
      you're welcome. i'm just waiting to see what my bill shows for my hospital stay for prep. :O i got 2 different stories so we'll see.

      Comment


        #4
        I'm hoping that you will be ok. As long as you have secondary insurance with Medicare (a Medigap plan - or an employer retirement plan) that picks up the 20% that Medicare doesn't pay for Part B charges, then you should be ok.

        The medication part confuses me though.... It sounds like you have to bring your own medications (?) since Part B doesn't pay for medications. Who the heck would know to do that?!?! It is just crazy.... If they gave you any pill/liquid medications there, then that is what I would be wondering about. It looks like the IV medications are covered.

        We keep a list for my father about what to bring if he ever needs to go to the Emergency Room. I have always had on the list to bring his medicines for at least the next day... but now I'll make sure he brings enough for the next 3 days!

        Thanks again.

        Comment


          #5
          What justifies having the surgery done? I know that it would make my life easier but would that be reason enough to justify for insurance to cover the procedure?

          Comment


            #6
            Originally posted by Brent K View Post
            What justifies having the surgery done? I know that it would make my life easier but would that be reason enough to justify for insurance to cover the procedure?
            Are you having surgery?

            Not sure how your question relates to this thread. Cass is posting about the financial challenges of changing Medicare coverage for short hospital stays if they are classified as "observational" stays.

            Comment


              #7
              Hey Cass,

              This is what I was trying to explain to you in all my not so explainable posts.

              HLH- They will still give you your medicines in the hospital as long as the physician writes an order for it. Most hospitals that I have worked in and been a patient in has specific policies about patients bringing in their own medicines. Due to risk of the doctor prescribing something in the hospital that may interact with the medicine that the patient takes normally, most prohibit patients bringing their own meds.

              Ok back to the observation status.....since it is billed as outpatient and to Part B. They can only bill you the 20% of what Medicare would pay for the allowable charge. Anything that they try to charge you over that would have to have a "Advanced Beneficiary Notice" signed by the patient.

              It looks like this:

              http://www.advancebeneficiarynotice....0CMS-R-131.pdf

              It has to be filled out completely and specifically for the "items" that are not going to be covered. Most hospitals have not got this down yet even though it has been 10 years since CMS/Medicare they came up with it.

              If any part of the ABN is blank then the whole form is void and they cannot fill in after you have your services.

              Here are the instructions for the hospitals to follow:

              http://www.advancebeneficiarynotice....282%29tcec.pdf

              You may have not ever seen one because it is alot of paperwork for the hospital to go through. It was much easier for me when I had the patient in front of me to call the physician and ask why this patient was having the test. Most times the doctors office just added the diagnosis that was on the chart and not from what the doctor actually dictated in his note for the test.

              Given your previous bills Cass....I am going to bet that your hospital bills you for some of the charges that Medicare does not allow for. I have not done such a good job explaining things to you.

              But I know from my own experience currently. I get at least one erroneous item billed to me that Medicare does not allow for almost MONTHLY. Most recently it was a $2500 office visit....YES!!! I saw a therapist who was teaching me the Cognitive Behavioral Therapy for managing pain. He had an assistant who sat in on the visit. Actually he was a medical student from Duke University. They can bill for both doctors seeing the patient by calling him an assistant when he actually is learning. But Medicare will probably not pay for a second charge. That is how they gouge insurance companies too. So my doctor charged $249 for that hourly visit but the assistants charge was $2499. So I got a bill for $3000 for one visit. I called and customer service apologized profusely because my insurance had not even been billed. They can only charge half of the doctors charge for the assistant and on and on and on. There were also charges from other days and it turns out I had 4 mistakes in this cumulative bill they kept sending.

              End of story....I had paid all my copays up front at every visit and I did not owe them one dime. But that did not stop them from sending me to collections for a $400+ bill they kept saying that I owed.

              I know I keep saying this to you but NEVER JUST PAY A BILL without knowing what Medicare allows for the service. Hospitals collect alot of money that they are not entitled to just by sending out these cumulative billing statements. The elderly and disabled are especially vulnerable because with multiple visits, it is hard to distinguish what Medicare pays.
              T12-L2; Burst fracture L1: Incomplete walking with AFO's and cane since 1989

              My goal in life is to be as good of a person my dog already thinks I am. ~Author Unknown

              Comment


                #8
                Hi DD,

                Yeah, the Medicare world can be very confusing, and this new expansion of the Observation status for hospital admissions is something important for us all to know.

                The info Cass posted states that Medicare will not cover medications if you are admitted under Observation status, because then everything is paid by Medicare part B (which doesn't include a drug plan) instead of A. The explanation is very incomplete in this regard, and suggests you should bring your own medications.

                Yes, for a normal hospital stay the medications are covered when the doctor prescribes them, but reading the document Cass posted should make everyone concerned that this may not be the case if they are admitted under OBS.

                Comment


                  #9
                  Originally posted by hlh View Post

                  The info Cass posted states that Medicare will not cover medications if you are admitted under Observation status, because then everything is paid by Medicare part B (which doesn't include a drug plan) instead of A. The explanation is very incomplete in this regard, and suggests you should bring your own medications.
                  I have not worked in the hospital with outpatient issues since 2009. I have done some research and some things have changed it seems. Here is a good reference sheet straight from Medicare.

                  http://www.cms.gov/Outreach-and-Educ...ds/11315-P.pdf

                  I can't believe what a mess this must be creating in hospitals.

                  They can't bill part D so I am thinking some of them may be relaxing their requirements for observation patients. But you have observation patients like Cass who are there for a specific non life threatening purpose then you have observation patients who have chest pain. I cannot imagine a doctor allowing someone in observation for chest pain (an example) take their own prescribed pills and it not creating a liability for the hospital and the doctor just because of coverage issues.

                  I would have to ask a former coworker to get an exact answer but I bet the hospitals still write off the drugs when forced to. Here is my reasoning...if the ABN is not signed and specifically completed, then the beneficiary is not responsible for non-covered items. They can't just write medication, it has to specify which medication.
                  T12-L2; Burst fracture L1: Incomplete walking with AFO's and cane since 1989

                  My goal in life is to be as good of a person my dog already thinks I am. ~Author Unknown

                  Comment


                    #10
                    Well I guess I accidentally found the answer.

                    Medicare does not require ABNs for statutorily excluded care or for services Medicare never covers. However, in these situations, you may issue an ABN voluntarily. Refer to the “What Claim Reporting Modifiers Do I Use?” section at the end of this booklet for information on claim modifiers associated with voluntary ABN use.Examples of Medicare Program exclusions include:


                    Self-administered drugs and biologicals (i.e., pills and other
                    medications not administered by injections);



                    http://www.cms.gov/Outreach-and-Educ..._icn006266.pdf
                    So they do not have to notify you of non-covered drugs. We should know these are not covered and therefore responsible for payment.

                    In that link there is a whole list of stuff that we as Medicare Beneficiaries should know is not covered. I can't copy and paste from that publication so look under the title of "When may I issue and ABN".

                    This is from Medicare teaching providers what they can and cannot bill for.
                    Last edited by darkeyed_daisy; 2 Apr 2013, 4:42 PM.
                    T12-L2; Burst fracture L1: Incomplete walking with AFO's and cane since 1989

                    My goal in life is to be as good of a person my dog already thinks I am. ~Author Unknown

                    Comment


                      #11
                      Originally posted by darkeyed_daisy View Post
                      Well I guess I accidentally found the answer.



                      So they do not have to notify you of non-covered drugs. We should know these are not covered and therefore responsible for payment.

                      In that link there is a whole list of stuff that we as Medicare Beneficiaries should know is not covered. I can't copy and paste from that publication so look under the title of "When may I issue and ABN".

                      This is from Medicare teaching providers what they can and cannot bill for.
                      The page for won't come up for me daisy.

                      I think if they take Medicare they should tell you want is not covered.

                      When you are sick you have no time or to sick to know whats really going on.

                      Art
                      Art

                      Comment


                        #12
                        Originally posted by Art454 View Post
                        The page for won't come up for me daisy.

                        I think if they take Medicare they should tell you want is not covered.

                        When you are sick you have no time or to sick to know whats really going on.

                        Art

                        I fixed the link Art. It should work now.

                        The list starts on page 6

                        Personal comfort items;
                        Self-administered drugs and biologicals (i.e., pills and other
                        medications not administered by injections);
                        Cosmetic surgery (unless required for prompt repair of accidental
                        injury or for improvement of a malformed body member);
                        Eye exams for the purpose of prescribing, fitting, or changing
                        eyeglasses or contact lenses in the absence of disease or injury
                        to the eye;
                        Routine immunizations (except influenza, pneumococcal, and
                        hepatitis B vaccinations; specific regulations regarding benefici
                        ary responsibility apply for these services)


                        X-rays and physical therapy provided by chiropractors;
                        Hearing aids and routine hearing examinations;
                        Routine dental services (i.e., care, treatment, filling, removal
                        , or replacement of teeth);
                        Supportive devices for the feet;
                        Routine foot care (i.e., cutting or trimming corns or calluses,
                        unless inflamed or infected;
                        routine hygiene or palliative care or trimming of nails);
                        Services furnished or paid by government institutions;
                        Services resulting from acts of war; and
                        Charges made to the Medicare Program for services furnished by a physician or supplier to
                        his or her immediate relatives or members of his or her household.
                        T12-L2; Burst fracture L1: Incomplete walking with AFO's and cane since 1989

                        My goal in life is to be as good of a person my dog already thinks I am. ~Author Unknown

                        Comment


                          #13
                          Originally posted by smashms
                          in the US MOST if not ALL hospitals not matter what you are there for WILL NOT ALLOW YOUR OWN MEDS BE TAKEN. Darkeyed Daisy is correct in this case HLH, I have personal knowledge in this situation. DD does know what she is taking about here because she used to do this for a living.

                          Sure, but my mom took her own meds a few times in the hospital. It depends on the situation. No need to yell.

                          I think you missed the point of our discussion. We are not talking about a "normal" hospital admission and not even who physically gives you the pills - we are talking about coverage for medications if you are admitted as an Observation status patient now and have Medicare coverage. I certainly don't know how the nurses plan to administer you your own meds, but if you read the document Cass posted (and DD is confirming), they state Medicare will not cover your medications if you are admitted for a 3 days observational stay and ask the hospital to give you meds from their stash.

                          Cass, let us know what happens to billing for any medications you received while hospitalized. Thanks a bunch.

                          Comment


                            #14
                            i took my own medications in. it was not a problem. they just had to have the hospital pharmacy look at them, then i got them back. i do have a secondary plan from work.

                            Comment


                              #15
                              Originally posted by hlh View Post
                              3 days observational stay
                              Observation is technically only 24 hours but can last up to 48 hours. The hospital rarely gets paid for more than 24 hours observation time.

                              There is a class action lawsuit. People who have chronic conditions that don't meet admission requirements for hospitals are being sent to skilled care facilities after an observation stay. For the skilled care facilities to be paid for the visit, the patient has to have a "three day qualifying stay" in a hospital.

                              You have to meet certain conditions to be admitted to an acute hospital but even though some patients are really ill and need care, they don't meet those conditions.

                              Observation is a huge mess. The hospital in my town got slapped with fraud in the millions of dollars for wrongly billing observation visits. If your doctor does not write an observation order and you don't meet admission criteria for acute care....the hospital is responsible for those charges. I think we will see a whole lot more fraud charges coming down from the Department of Justice regarding observation.

                              The admission hinges on one thing and that is the order the physician writes. Doctors are hard-headed people sometimes.

                              Even if a physician orders that a beneficiary be admitted to a hospital as an inpatient, since 2004 CMS has authorized hospital utilization review (UR) committees to change patients' status from inpatient to outpatient. Such a retroactive change may be made, however, only if (1) the change is made while the patient is in the hospital; (2) the hospital has not submitted a claim to Medicare for the inpatient admission; (3) a physician concurs with the UR committee's decision; and (4) the physician's concurrence is documented in the patient's medical record.[4] CMS explains that retroactive reclassifications should occur infrequently, "such as a late-night weekend admission when no case manager is on duty to offer guidance."[5] Although CMS anticipated in 2004 that reclassifications would be used less frequently over time,[6] the Center has heard about this practice only recently.
                              http://www.medicareadvocacy.org/medi...vation-status/


                              http://www.naplesnews.com/news/2011/...icare-lawsuit/

                              http://californiawatch.org/dailyrepo...problems-16444
                              T12-L2; Burst fracture L1: Incomplete walking with AFO's and cane since 1989

                              My goal in life is to be as good of a person my dog already thinks I am. ~Author Unknown

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