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Valued Contributor
Posts: 555
Registered: ‎03-11-2010

Re: Medicare won’t cover you if you’re hospitalized for observation.

My husband is 87 and I am 70. We moved from NYC to Florida 7 years ago.

My husband is a doctor, I worked for him do the insurance billing. I know quite a bit about how Medicare works.

 

In his practice, we learned that Medicare Advantage was a nightmare. I could spend hours and days trying to collect payment for his patients. When they did pay it was such a small amount, I was forced to bill the patient for the balance.

 

Medicare Advantage then required doctors to be in their system to collect anything.

 

We decided to stop accepting patients with Medicare Advantage.

 

My husband retired at age 78. While he worked we both had Aetna primary and he had Medicare as secondary. After retirement, Medicare became primary.

 

We both learned early on that his patients who had straight Medicare with AARP (United Healthcare), paid the most. So when he retired, we used AARP as our secondary.

 

Once I reached 65 I did the same. Both of us have been covered for everything. My husband has multiple health problems. Had two stents put in at age 74 when Medicare was secondary (he was still working full time). I could write pages about problems he's had over the years.

 

When we moved to Florida (Sarasota) seven years ago, he has had so many ER runs due to bleeding (on blood thinners because of the stents), he was seen in the ER and released when they got the bleeding under control. No charges at all. He was not admitted.

 

He called 911 last year because of dizziness and got nervous. I was not happy but wasn't sure what was wrong. Taken by ambulance to ER, they ran a dozen tests and couldn't find anything wrong. They held him overnight in the ER. Never paid a penney.

 

Last year, I got a sudden, severe headache and thought I was having a stroke. I told my husband to get me to the ER and he drove me there. I had a battery of tests and was kept in the ER overnight. They couldn't find a cause. Didn't have to pay a penney.

 

I read what Medicare pays, but am not sure why we were covered for multiple ER visits without admission. Maybe what our doctors wrote, but the few overnights in the ER didn't cost us anything.

 

I didn't read all the posts above, not sure if you had an Advantage Plan. I do know they have their own rules as they are not Medicare. They are private companies who work for profit by cutting costs to the patient. They take your Medicare payments and pay less and make a profit off Medicare.

 

In my opinion, Medicare Advantage should be stopped. The elderly do not understand how it works and how they control what doctors and hospital can do.

 

We both travel back and forth to NY to visit our grown kids and grandkids and have used medical services there without any problem or charges. Straight Medicare covers you no matter where you are in  the Country. AARP (United Healthcare), does the same as long as the doctors and hospitals accept Medicare. We haven't found any doctor or hospital who doesn't accept Medicare. Many doctors do not accept Medicare Advantage nor can you travel outside your State and have coverage by Medicare Advantage.

 

Not sure what your coverage was, but if regular Medicare, you should have been covered unless your doctor messed up. I would have fought it.

 

 

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Honored Contributor
Posts: 13,714
Registered: ‎03-09-2010

Re: Medicare won’t cover you if you’re hospitalized for observation.


@Patbz wrote:

@lovesrecess :  I have Medicare and BCBS and Medicare is primary.


 

@Patbz 

 

Same here.

You never know how strong you are until being strong is the only choice you have.
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Esteemed Contributor
Posts: 6,425
Registered: ‎03-09-2010

Re: Medicare won’t cover you if you’re hospitalized for observation.


@Mindy D wrote:

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@Mindy D  do you know if this page is in the Medicare & You book or is it just the website?

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Trusted Contributor
Posts: 1,575
Registered: ‎03-28-2010

Re: Medicare won’t cover you if you’re hospitalized for observation.


@Mindy D wrote:

Ray Callahan was having chest pains and thought he could be having a heart attack. He went to the ER at Northwest Medical Center in Margate, FL. He was tested in the ER where doctors found a blood clot. Ray says “They took some pictures and came back and told me I had a large blood clot in my lung and I needed to stay in the hospital.” He stayed in the hospital for three days. When he asked the doctors  to go home, according to Ray;  “They said ‘no, we need to monitor you and make sure that the blood clot does not get loose and cause further damage.” Ray had enrolled in Medicare Part A and thought his hospitalization was covered by this. The hospital, instead, billed his work health insurance plan. He called hospital billing and spoke to someone that told him that he was in for observation and that Medicare Part A does not cover hospitalization for observation. He was told he was never technically admitted. On his hospital discharge papers there was a notice that said “Your physician placed you in the hospital as an outpatient and ordered services, but did not formally admit you as an inpatient. The reason for this notice is that Florida law requires that hospitals notify patients of their outpatient observation status upon discharge because your outpatient status may affect the amount you pay for your hospital services.” My post is based on an article I read by “NBC6 Responds.” The writers contacted Medicare about this were and were told that Medicare Part A does not cover observation and that hospitals have to classify a patient’s stay. Medicare also informed the NBC6 Responds reporter that if a beneficiary is still employed that the work insurance is considered primary insurance over Medicare.

My information was obtained from the online article “Man Mistakenly Thought Medicare Would Cover Hospitalization” by Alina Machado. Published Oct. 4, 2019. NBC 6 South Florida

 

 


It's not just Medicare.  Other insurance companies do the same. 

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Honored Contributor
Posts: 22,219
Registered: ‎05-10-2010

Re: Medicare won’t cover you if you’re hospitalized for observation.

Okay, this what really happened.  Part A covers inpatient admissions.  However, when you are in Observation in a hospita, and you can be in observation for up to 72 hours; that is not inpatient. Observation for all insurers Medicaid, Medicare, Blue Cross and all commercial insurers is outpatient.  There is nothing new about that, it's always been that way.  The problem is that Obersvation is more of term that applies to billing than to patient care.  A patient who is on observation status in the same unit, same bed, receives the same care and treatment as a patient who is inpatient.  In the past, physicians (who don't consider billing) didn't tell patients when they were admitting them as observation.  And the patient would have no way of knowing.  All they patients knew was that they were in the hospital for 2 days.  Those patients were the shocked when the got their EOB's and the bills.  They were billed for thousands of dollars and most didn't understand why.  Some states now mandate that hosptital inform a patient when they are admitted for observation.  Part A does not and never did pay Observation charges.  Also those patients who are still working and covered by group insurance and Medicare must submit their bills to group insurance first and the balance is then submitted to Medicare.  That has always been the case too.  Some people think they have a choice, they can use Medicare or Group Insurance as they choose but that is not the case.  Your insurance through work is primrary insurer.  On top of that, physicians don't have the discretion of admitting a patient as inpatient or observation.  There are very clear clinical guidelines that must be met for admitting a patient as an inpatient.  So, when a doctor admits you, it's up to the patient to ask if they are being admitted as an inpatient or as observation (i.e. outpatient) and then to consider how the claim will be paid and what the patient balance will be.  They have the right to consult with Patient Finance about this anytime.  The thing to remember is that observation is not in terms of billing a hospital admission, it's  billed and paid as an outpatient visit.  

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Honored Contributor
Posts: 22,219
Registered: ‎05-10-2010

Re: Medicare won’t cover you if you’re hospitalized for observation.


@Kachina624 wrote:

This is but one reason I'm glad I don't live in Florida.


 

       This has nothing to do with FL.   It's a Medicare.  It applies to all Medicare care patients everywhere.   

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Regular Contributor
Posts: 186
Registered: ‎01-29-2017

Re: Medicare won’t cover you if you’re hospitalized for observation.

Yes, knew about "observation"......As for "advantage" plans, they are in our opinion, no advantage at all. You pay less in premiums, but coverage is not as good as Original Medicare plus a supplementary plan. When we turned 65, we chose Original MC plus supplementary (Medicare parts A & B), and Prescription plan. You will notice many plans advertised on tv right now for "Advantage" plans with low copays etc, but you have to use MDs in a network and the hospital you want to go to may not want you. One pays more out of pocket for non Advantage plan premiums, but if you can swing it, those of you not yet 65, talk with a financial adviser and see for yourself. Take care.....

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Honored Contributor
Posts: 22,219
Registered: ‎05-10-2010

Re: Medicare won’t cover you if you’re hospitalized for observation.


@Mindy D wrote:

@Tyak wrote:

He was in the hospital for 3 days and had not been admitted?  That doesn't sound right to me.  


It’s all in the words and codes the hospital uses to classify your stay. If you are taken into the hospital terms Observation, and Admitted are different. This man’s ER doctor could have written Admit for treatment for blood clot and he would have been considered admitted. Instead, the ER doctor wrote observation. Ridiculous, but that’s how things work right now. 

 

You watch too man medical tv shows.  That's not at all what happens when a patient is admitted.  Physicians can't just willy nilly write an order to admit a patient as inpatient or observation like they would choose a sandwich vs a salad in the cafeteria.  Observation vs Inpatient is determined by clinical guidelines.  Certain medical criteria and the treatment plan must be met first and that determines observation or inpatient which is called Level of Care.  Medicare and insurers audit bills and medical records and they (we because I worked as such an auditor)  look specifically look for this type of infraction.  Hospitals face signigicant fines if they are caught billing for incorrect Level of Care.  


 

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Honored Contributor
Posts: 22,219
Registered: ‎05-10-2010

Re: Medicare won’t cover you if you’re hospitalized for observation.


@lovesrecess wrote:
  1. It’s all about the coding! It has to be coded a certain way before they cover anything at all, not just in Florida.

 

 

Trust this Coder,  you're wrong.  You don't know what medical coding is or how it applies to anything.  Observation vs Inpatient has absolutely nothing to do with the coders.  When we code a claim THAT isn't something we code.


 

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Honored Contributor
Posts: 22,219
Registered: ‎05-10-2010

Re: Medicare won’t cover you if you’re hospitalized for observation.


@lovesrecess wrote:
My hospital has a section where I was sent when I went to ER due to having a hard time breathing... It was a new area with ten beds all in one room and flimsy curtains between them,...looked like it was from an old war movie...I called it purgatory...found out it was where they put ER patients when they weren’t sure where to put them....regular floor or ICU. They could keep you there up to two days. I finally went to a regular floor, but wasn’t officially admitted until the third day. Was just in purgatory😎

 

I have heard that some hospitals do it that and I think that is an absolutely awful and mean thing to do.  I know that the hospitals in my state do not have special areas for Observation patients.  Observation is a "status" here and not a specific place in the hospital.  Everything is computerized in hospitals now so alerts go to the attending physicians electronically.  The alerts are to remind that they have an observation patient and if that patient meets the medical criteria for an inpatient admission, they MUST admit that patient NOW.  That way patients only stay in observation as long as it's medically appropriate.