Thursday, April 8, 2010

Observation vs. Admission

For those who don't know, traditional Medicare will cover a short time (up to 100 days) in a skilled nursing facility. In order to qualify for this benefit, a person has to have a three day (midnight) stay in the hospital, and have a medical or rehab need.

This benefit is a lifesaver for many families. Hospital lengths of stay have been getting shorter and shorter, so sometimes when Mom or Dad has been hospitalized due to an accident or planned surgery, they need a bit more time somewhere before they go home, and this has usually been the local skilled nursing facility.

Something that is happening with increasing frequency is people going to the emergency room and never actually being admitted to the hospital, even if they are in the hospital for 3, 4 or more days. If you are wondering how that can be, let me tell you in a word--observation.

It is possible to spend days in the hospital without ever actually being admitted, and this has been a hot topic this week in a list serve I belong to. Geriatric care managers from all parts of the country are running into this problem, and it is a problem for older adults, because in more and more instances they don't find out that they were never admitted to the hospital until after they have spent time in the skilled facility (sometimes to the tune of $375/day) and get the bill, because Medicare tells them, correctly, that they did not meet the admission criteria.

The reasons this is happening are varied, and as is usually the case, boils down to money. Hospitals are under great pressure to decrease inappropriate admissions--when the person doesn't really need to be in the hospital; AND they get penalized for re-admissions--when a patient is discharged, only to show up back in the ER a few days later. So, instead of admitting people, they just "observe" them, sometimes for days.

So, the moral of this story: if a loved one is hospitalized (especially an older adult), make sure you know their admission status. If the doctor doesn't know, and don't be surprised if he doesn't, ask the case manager, because she usually will. It's better to bug the people at the hospital about admission status than it is to run the risk of a hefty skilled nursing bill.

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