Wellness

[ALRATIBA]

in 2019 ...  I had a rather bad fall - ambulance - emergency room (Saturday morning) all sorts of scans and xrays.  Nothing broke but bad pain.

Admitted - some Tylenol and lidocaine patches - interviewed by every sort of doctor imaginable ... released Monday and went home.  

Between Medicare and retirement benefit supplement ... total out-of-pocket was about $100 (including ambulance to hospital and "ambulette" home.

[granddi]

www.verywellhealth.com › an-explanation-ofAn Explanation of Inpatient vs. Observation Status

Observation status means that have a condition that healthcare providers want to monitor to seeif you require inpatient admission. Observation status is an outpatient status, but it can also

[Love my grandkids]

@Mindy D I asked this years ago when I was in the ER at my local well known and highly rated hospital. The doctor told me that pretty much don't do the "admitted for observation."  They treat in the ER  and discharge or they admit. That's been my experience for years.

[Mindy D]

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@skatting44 wrote:

@Mindy D 

 yes, hospitals make it clear to patients  as to if they are being placed on 23 hr observation  or are being admitted .  If a  patient does not meet discharge criteria  after the 23 hrs ( Medicare part B or private insursance )  , then  the 23 hr billing ends and new billing ( under Medicare part A  or private insurance )  begins as a regular inpatient .

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@skatting44 But is everything during the 23 hours charged as an outpatient if the patient is finally admitted?

[Still Raining]

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@Mindy D wrote:

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@skatting44 wrote:

@Mindy D 

 yes, hospitals make it clear to patients  as to if they are being placed on 23 hr observation  or are being admitted .  If a  patient does not meet discharge criteria  after the 23 hrs ( Medicare part B or private insursance )  , then  the 23 hr billing ends and new billing ( under Medicare part A  or private insurance )  begins as a regular inpatient .

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@skatting44 But is everything during the 23 hours charged as an outpatient if the patient is finally admitted?

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My region is serviced by Noridan and this is their current instructions:

Hospitals paid under the Inpatient Prospective Payment System (IPPS) must include all outpatient diagnostic and admission-related non-diagnostic services provided up to three calendar days preceding the date of admission as an inpatient. All services other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital), provided during the 3-day bundling window are deemed related to the admission and are not separately billable, unless the hospital attests otherwise.

The 23 hour rule is from long ago.

[Still Raining]

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@CelticCrafter wrote:

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@Still Raining wrote:

Observation is a dedicated unit, often indicated on the license, for a type of subacute care.  There are written guidelines (clinical) for admission and discharge.

Basically you are not sick enough to be admitted and too sick to go home.  It does have time limits.

In smaller hospitals it can also be used as a late night recovery room, in which case you will be admitted.  Some rural hospitals may switch the beds over to SNF as needed.

I have never heard of any insurance that will not cover this care.

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@Still Raining it's listed right in the Medicare and You handbook that it won't be covered.

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Could you please copy the section?

[granddi]

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@Still Raining wrote:

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@CelticCrafter wrote:

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@Still Raining wrote:

Observation is a dedicated unit, often indicated on the license, for a type of subacute care.  There are written guidelines (clinical) for admission and discharge.

Basically you are not sick enough to be admitted and too sick to go home.  It does have time limits.

In smaller hospitals it can also be used as a late night recovery room, in which case you will be admitted.  Some rural hospitals may switch the beds over to SNF as needed.

I have never heard of any insurance that will not cover this care.

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@Still Raining it's listed right in the Medicare and You handbook that it won't be covered.

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Could you please copy the section?

www.medicare.gov › what-medicare-covers › what-partInpatient or outpatient hospital status affects ....

The decision for inpatient hospital admission is a complex medical decision based on your doctor’s judgment and your need for medically necessary hospital care. An inpatient

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[chrystaltree]

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@CelticCrafter wrote:

Under observation is not covered by insurance unless it results in being admitted.

You are totally wrong!

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[chrystaltree]

This is part of what I did professionally for ,many years.   It's a little complicated.  In your case, Observation was correct.  The care provided did not meet inpatient criteria.  Not for any insurer .   Observation is something Medicare and insurers invented to decrease payments to hospitals.  They pay much less for Observation.  Observation means the patient does not meet the inpatient clinical criteria so it's considered to be outpatient care and reimbursed as such.  However in most cases the patient is in an inpatient bed and receiving the exact same care as if they had been admitted as inpatient.  For example, a patient who has abdominal pain without a clear diagnosis, will be admitted as observation as they treat him, do the tests etc.  Generally observation is 23 hrs, 48 hours for a few insurer.  If the patient stays beyond the 23 hrs  hours, the hospital must discharge the patient or convert the patient to inpatient status.  If they do that, the hospital must contact Medicare or the insurer to provide clinical information that supports inpatient criteria.  For example, the patient with abdominal pain is now receiving IV fluids and IV pain meds.  Exploratory surgery has been ordered if he does not improve in 12 hours.  From the patient perspective, it doesn't matter if they are observation or inpatient because the care is the same.  

[Carmie]

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@CelticCrafter wrote:

Under observation is not covered by insurance unless it results in being admitted.

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This is not true at all.

Hospitals have to have to follow inpatient guidelines to admit you as an inpatient.

Sometimes they admit you  for observation, which is paid as an outpatient claim.

If a hospital admits you as an inpatient and they do not meet the inpatient guidelines or they did not have prior precertification to admit you, the insurance will deny the whole claim and they will get zero payment.

Observation will pay and does not require precertification.  It used to be for up to 24 hours, now they can bill up to three days of observation care.

It is intermediate care that admits you just like an inpatient, but pays the lower outpatient rate.

All insurance will pay for observation care as long as it is medically necessary.

It is quite popular today and saves insurance companies money and save hospitals the trouble to get precertification for an inpatient admission.