Medicare: Observation vs Admitted
Knowing if you are admitted to the hospital or if you are under observation could be the difference of a few thousand in savings. One would assume if you are receiving treatment or have been in a hospital for a few days that you would be admitted. However, there have been incidences of patients being under observation for more than 10 days!
Always ask what your status is.
Without a Medicare Supplement plan, your status can affect what you pay for various services such as X-rays, prescription medications, and lab tests during your stay. However, even with a Medicare Supplement plan your status will affect what Medicare will cover after your stay.
Should I be worried if my status is “observation”?
It is typical for patients to initially be in observation (aka an outpatient) prior to being admitted (aka an inpatient). As the name suggests, observation is a period of time where the doctor can provide services and determine if you should be discharged or admitted. As a Medicare recipient, you should only be in observation for 24-48 hours as recommended by Centers for Medicare & Medicaid Services (CMS). It is also required that you receive a Medicare Outpatient Observation Notice (MOON) within 36 hours of being in observation for 24 hours.
Always ask if Medicare will cover your skilled nursing facility stay.
If you are under observation and will need to go to a nursing home for rehabilitation or a similar facility, Medicare will not pay. However, if you are admitted for 3 or more days Medicare will cover a stay.
So how do you become “admitted”?
A doctor must write an order to have you admitted and the order must be processed by the hospital to officially change your status. This a complex medical decision and there is no specific formula to guarantee you will be admitted. However, below are some suggestions when trying to change your status to admitted.
If you are still in the hospital:
- Ask the doctor to admit you.
- If the doctor or the hospital insist on an observation status, ask for written documentation stating why they determined that status. This will especially be useful if you need to make an appeal once you are discharged.
- Inform the doctor or hospital that you want your status changed because the care is “medically necessary” and an “inpatient hospital level of care.”
If you are no longer in the hospital:
- You might be able to make an appeal, but winning these cases is becoming increasingly difficult. However, on March 25th 2020 U.S. District Judge Michael P. Shea ruled in a class action to force the government to provide Medicare patients the ability to appeal denials of coverage relating to your status. Regardless, it will help to have your doctor from your stay aid in the appeal.
