Updated: May 25, 2022
For family caregivers, certain events herald that significant change is on the way. One of these is the sudden appearance of the “revolving door” pattern. Mom suffers a medical crisis, goes to the ER, is admitted for a few days until stabilized, then discharged to inpatient rehab in a nursing home, then goes home. Then it happens again: medical crisis, ER, hospitalization, inpatient rehab, then discharge to home. And the cycle continues to repeat itself ….
The revolving door pattern is a big deal. It is a sign that what was once a care watch situation is now in care warning situation. The storm is beginning to make landfall.
A serious Medicare coverage issue arises if the patient is held over for one or more days in the hospital. Here are the basics for traditional Medicare coverage. Medicare A pays for care in the hospital. Medicare B pays for outpatient services. Upon arrival to the ER, the patient is classified as receiving outpatient services and Medicare B provides the coverage.
If the patient is held over one or more nights without a formal medical order for skilled treatment, Medicare will classify this as Admitted for Observation. Medicare B will continue to apply along with its attendant deductibles and copay requirements. Coverage for some services may be denied altogether. This can become extremely expensive.
For Medicare A to cover the charges for staying in the hospital, the patient must be admitted based on a physician order for skilled care. Medicare classifies this as Admitted for Treatment. Medicare A will cover all the charges from arrival in the ER through discharge. Just because the patient was sent up to a floor from the ER does not mean they were Admitted for Treatment.
A caregiver must understand the Medicare classification of the patient as early as possible. Begin asking about the classification as soon as it appears that the patient is not going home within 24 hours of arrival at the ER. Stick with it until the medical or administrative staff clarifies whether the admission is for Observation or for Treatment. Do not assume anything.
May 4, 2022