New Medicare Law to Help Close Loophole in Nursing Home Coverage
You have an urgent medical problem, so you go to the hospital, where you’re kept under observation for several days. Your doctor then recommends a short stay in a nursing home for rehabilitation. Because you’re covered by Medicare, you assume those nursing home costs will be paid for, since Medicare typically covers up to 100 days of rehabilitative care following surgery or some other qualifying medical procedures.
So imagine how you would feel, after returning home, to get a bill for the entire amount of the nursing home stay. That’s what’s happening to thousands of seniors. The reason: the hospital never formally admitted you as an inpatient. Instead you were kept under observation status, and because of that, Medicare will probably decline to pay for your rehabilitative care.
On our radio program and in our law practice, we receive many calls from people who have experienced this shock. Now finally comes a brand new law that requires hospitals to inform patients that they are being kept under observation status and not being admitted as regular patients, leaving them personally liable for any subsequent charges for a rehabilitative stay in a nursing home. This at least alerts the patient and allows them to consult with their physician, hopefully to get the hospital to change their status to that of an in-patient so any future rehabilitation will be covered by Medicare.
This problem, which until now has not been widely publicized, was recently highlighted in this revealing article on the website of the New York Times. It spotlights the story of an 85 year old Pennsylvania woman who was hospitalized for six days of “observation” as a result of a fall. She then spent five months in rehabilitation in a nursing care facility, most of which should have been covered by Medicare. Instead she received a bill from the nursing home for $40,000. Medicare refused the charge because the hospital had never formally admitted her.
What’s going on here? According to the New York Times, it all has to do with the economics of modern health care. “Hospitals have been keeping patients…in limbo – in ‘observation status’ – for fear of being penalized by Medicare for inappropriate admissions,” reports the Times. Medicare won’t pay for nursing home stays following hospitalization unless the patient has been in the hospital for at least three consecutive days – and days spent “under observation” don’t count! No wonder patients and their families are feeling blindsided.
The new law requires hospitals to tell any patient who stays longer than 24 hours that they are under observation status and that any future rehabilitation may not be covered by Medicare. This law passed with strong bipartisan support, and proponents expect that the new law will require hospitals to issue some 1.4 million notices a year. But in our view, and that of most experts in senior health care, the more important next step is to change the law so that time spent under observation counts toward the three-day Medicare qualification for rehabilitative care. Until then, patients and their families have got to be on guard to avoid major sticker shock after Mom or Dad comes home from a temporary stay in a nursing care facility.
We suggest you read the article in the New York Times, then check with your elected representative in Washington, DC, to see if he or she is among those supporting long-overdue Medicare reforms in the rules governing hospital admission. This loophole needs to be closed!
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(originally reported at www.nytimes.com)