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Honored Contributor
Posts: 25,929
Registered: ‎03-09-2010

medicare admitting patients as observation instead of admitted to hospital ...

On Thursday afternoon my DH had a small stroke. I took him to the ER and he is going to fully recover. However, they no longer , from what the ER doctor explained to us, admit anyone as a true admission anymore but instead admit you as an observation patient. By medicare rules - until they have a definitive diagnosis they can't actually admit you. The problem with this is --- when you are an observation patient they do not pay 20% of the 80 % they are supposed to pay and neither does your supplement or advantage plan. You - the patient - have to pay it. It took an entire 24 hours before they assigned my DH a diagnosis so we will have to pay our copay of $400 a day for the first 5 days he is in the hospital (I have no issue with that as we knew we signed up for that) + we will have to pay the 20% for the first day + our copay for the ER. I don't know how much it will be but I'm expecting it to run us a few thousand in the end of it all. That extra 20% feels like such a rip off to me. And it is not helping my DH one bit to know he is racking up these bills.

It seems to me that co pays are supposed to prevent people from using the ER inappropriately and I have no issue with that - but it also seems that once a person has a diagnosis that is appropriate - like my DH's stroke - that should be forgiven because, clearly, he did need to come to the ER and be admitted to the hospital for his condition.He was using the ER appropriately.

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Occasional Contributor
Posts: 14
Registered: ‎05-13-2010

Re: medicare admitting patients as observation instead of admitted to hospital ...

First let me say I hope your DH is well! Always upsetting to have a loved one in an emergent situation. Unfortunately, it's not just Medicare but most insurance carriers have the same rules. Their intent is to cut down on needless admissions to hospitals which in turn, in the long run, costs the insurance company and their insured more money. Generally, if a patient is in the ER and admitted as an Outpatient Observation, yes, your Outpatient benefits would apply. If you are then admitted as an Inpatient from observation, they can deem the entire visit as an Inpatient visit. Supplemental plans can pay for the 20% on an Observation visit. All plans have clauses and each is different on what they will pay and under what circumstances. I'm not discounting what has happened to you as I'm sure it's more than you need to deal with on top of your DH' s stroke. If he was admitted as an Inpatient, double check with your insurance company. A lot of times that's a game changer for how your benefits are applied. Wishing your DH a quick and full recovery!
Trusted Contributor
Posts: 1,251
Registered: ‎11-24-2014

Re: medicare admitting patients as observation instead of admitted to hospital ...

this obs rule has been in effect for many years. My father had surgery recently and was expected to stay overnight because his age and the fact that he takes blood thinners puts him at risk. When we met with his surgeon before the surgery, I asked him if his stay would be considered an OBS stay and he said yes, almost everything is anymore. Medicare issued that rule to make people pay more of the cost. It used to be up to 23 hours is not ad admission, but now it is even longer than that.

I'm done with P.C. Just say what you mean and mean what you say. It's easier.
Esteemed Contributor
Posts: 6,494
Registered: ‎06-22-2010

Re: medicare admitting patients as observation instead of admitted to hospital ...

Very sorry about your DH, HH! Glad he's ok. Seems like Medicare is looking for loopholes! I would be upset too! Good thing you were there and recognized the stroke symptoms! That was a God thing!

Don't cry for a man who's left you--the next one may fall for your smile.
-- Mae West
Valued Contributor
Posts: 730
Registered: ‎07-12-2011

Re: medicare admitting patients as observation instead of admitted to hospital ...

And without a 3 day admission, an observation patient can not be admitted to rehab or a skilled nursing unit. Remember, there is a penalty for readmissions and the hospitals are financially dinged and this ding was strengthened under Obamacare. We can all get mad at Medicare, but the hospitals are working their angle financially to avoid this penalty as well.

I hope your husband gets better. A close family member of mine fell and he was admitted under observation. He ultimately needed rehab and didn't qualify because he was "only" an observation patient. It is a sad situation.

Trusted Contributor
Posts: 3,694
Registered: ‎03-09-2010

Re: medicare admitting patients as observation instead of admitted to hospital ...

I hope your husband has a speedy recovery. Unfortunately, it's not just Medicare that shafts people on ER visits and most people don't find out how expensive it is with insurance until they have to use the ER. There was a time you could see or call your doctor when having symptoms and they would admit you to a hospital without all the ER rigamarole but I don't think that happens now unless your having surgery. My friends in Europe can't believe that people in this prosperous country can lost their life savings with one illness.

It's always a victory for me when I remember why I entered a room.
Frequent Contributor
Posts: 113
Registered: ‎10-09-2014

Re: medicare admitting patients as observation instead of admitted to hospital ...

Very sorry about your husband. I got a crash course in this when my Dad was hospitalized last year. Patients really need advocates to read ALL the fine print and argue for their loved one. It's exhausting.
Honored Contributor
Posts: 9,859
Registered: ‎03-09-2010

Re: medicare admitting patients as observation instead of admitted to hospital ...

It may be more which hospital you're in than Medicare itself although Medicare does come into play. Still, when I had to go to the ER after fainting twice within minutes in a public place, the hospital kept me in an ER bed even though by paperwork I was an admitted patient. (No beds available except the one I was already in; finally got the cardiologist to say I could leave after 36 hours as long as I agreed to return for more tests.) The bills I paid were not at all exorbitant although I did think some of the charges (before Medicare cut them down) were.

Hope in the end you do as well. I have traditional Medicare plus gap, not an Advantage plan. That may make a difference????

Honored Contributor
Posts: 20,248
Registered: ‎05-10-2010

Re: medicare admitting patients as observation instead of admitted to hospital ...

Observation vs inpatient is a reimbursement methodology, it has no affect on patient care. The patient is treated medically, not by reimbursement or level of care. Medicare and other insurers don't want to pay hospitals inpatient rates for short stay admissions, meaning admissions that are less than 72 hours. So, they deem them to be observations, which are reimbursed as outpatient encounters. Yes, subscribers are then, subject to outpatient deductibles. But the bigger problem is that hospitals are not paid fairly for the services and care given to the patient. At one time, observation was for minor diagnoses like abdominal pain, headaches, sprains, uncomplicated fractures. But Medicare, and then the insurers, upped the ante and opted to use time only. So, someone admitted for a heart attack who receives care and is discharged home 48 hours later, is an observation pstient. Actual cost of care might be $25,000 but the hospital gets only the observation payment. Soomething like $2000. Which is an approximation, it differs by insurer. Now you know why your local hospitals are closing down or merging with larger hospitals.
Honored Contributor
Posts: 11,126
Registered: ‎06-20-2010

Re: medicare admitting patients as observation instead of admitted to hospital ...

I'm sorry about your husband. I hope he fully recovers.

Is this something unique to an advantage plan? I remember my mom being hospitalized a jillion times and was admitted under ""observation"" several times and their supplement picked up everything Medicare didn't cover.