ElderLaw News — The Estate Planning & Elder Law Firm, P.C. — MD, VA, DC
ElderLaw News

ElderLaw News is a weekly e-newsletter that brings you reports of legal developments and other trends of vital interest to seniors and their advocates. This newsletter is brought to you by The Estate Planning & Elder Law Firm, P.C., William S. Fralin, Esq., President.

Hospital Admission Advisory

Do you know the difference between being admitted to a hospital as an INPATIENT or as someone UNDER OBSERVATION?

If you're eligible for Medicare, the difference can be very costly. Consider the scenario of Laraine Sickels, a retired teacher from Whidbey Island, Washington. At 71 she went to the hospital because she had fallen at a friend's house. It was determined that she had 3 breaks to her pelvis. She spent 5 days in the hospital, but during that time she was only considered "under observation." Unaware of this, when it came time to be discharged, she was released to a skilled nursing facility. That's where the problem started. She got good care there, but because she had not spent 3 days in a hospital as an inpatient, her 10-day stay at the skilled nursing facility was hers to pay. Medicare covers the first 20 days in a skilled nursing facility completely, as long as you've been in the hospital at least 3 days and have been classified as "inpatient". In addition, that same patient who was classified as "inpatient" will pay for days 21-100 at the skilled nursing facility at the rate of $144.50 per day, a fraction of the true cost. (Amanda Gengler, "This could hurt--a lot," Money Magazine, August 2012, p. 72-3)

So what's happening? Well, Medicare is attempting to trim expenses. One way they've decided to do this is that, for certain cases, the patient who may have only one ailment gets classified as "under observation" while tests are run. This classification allows them to reimburse hospitals at a lower rate. "In 2009, the most recent data available, observation stays topped 1 million, up 25% from 2007, according to a study published by researchers at Brown University." (Gengler, p. 72) From their point of view, your care is the same. Medicare just winds up paying a lot less.

So how can you ensure that you will have the favorable classification of "inpatient?" Well, first of all, you must ask what your classification is. If it is not "inpatient" then you must ask that your doctor review your situation and possibly take it to a hospital review committee. The time to get your status changed is while you are in the hospital, not after discharge, when it is impossible to do. Make sure everyone is aware of your past medical history or other risk factors which may favorably influence the classification. (Gengler, p. 74-75)

If you still remain "under observation," you have the option upon discharge of receiving home help, if that is a workable option. Medicare will cover some in-home help, even if you weren't "inpatient." Also, if you must go to the nursing home to recuperate, you can ask the nursing home to bill Medicare. That gets you in the system. You will be denied by Medicare, but after 2 denials, your case then goes to an administrative law judge. At that point, you will need the doctor involved in your care to testify or write a letter on your behalf. You may also want to consider help from an elder law attorney or from the nonprofit Center for Medicare Advocacy at www.medicareadvocacy.org. (Gengler, p. 74-75)


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The Estate Planning & Elder Law Firm, P.C. is an elder law firm. We represent older persons, disabled persons, their families, and their advocates. The practice of elder law includes estate planning, estate and trust administration, powers of attorney, advance medical directives, titling of assets and designations of beneficiaries, guardianships, conservatorships, and public entitlements such as Medicaid, Medicare, Social Security, and SSI, disability planning, income tax planning and preparation, care management, and fiduciary services. For more information about The Estate Planning & Elder Law Firm, P.C., please visit our website at http://www.chroniccareadvocacy.com.

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