The Medicare Change That Could Cost Your Clients Thousands of Dollars

Betty is shocked when I tell her we refuse to sign it. “This is just routine, and she has to sign it,” she says. (My mother looks at me like I’m crazy, but she does stop signing her name.)

Betty then says she will send the social worker.

Ann Marie, the social worker, arrives to explain why the paper must be signed and hands me a brochure titled “A Patient’s Guide to Observation Status.” On the last page of the brochure, and at the bottom, Question 14 is “Does Outpatient Services care count toward my three-day hospital stay for skilled nursing care?”

The answer is: “No, your time in Outpatient Observation Services does not count toward the three-day (consecutive) hospital stay required by Medicare before it will pay for services at a skilled nursing facility. If your status changes from Outpatient with Observation Services to inpatient, your three-day hospital stay begins from the time you become an inpatient.”

We still refuse to sign the form.

Dr. B the hospitalist (floor doctor) arrives to review my mother’s condition.

I tell him we need to change her status to admitted. He says that he is not authorized to do so, and that the case manager makes that decision.

After Dr. B leaves, the case manager calls me on my cell phone and insists that we sign the form. I reply that we need the status to be changed to admitted. She says it is the responsibility of the admitting doctor. I explain that the admitting doctor said it was her responsibility. At that point, I mention that I write a column in a national newsletter that has a large circulation.

The case manager then starts telling me about the Medicare requirements for admitted status, and that my mother doesn’t meet them. She says, “If she was on oxygen, I could help you.”

I reply that she is on oxygen, and there is stunned silence from the case manager. She says, “Let me check with the floor nurse, and I will call you back.” I reply, “No, we are going to take care of this right now,” and I walk to the floor nurse and hand her my phone.

Ten minutes later the paperwork has been completed, and my mother’s status is now admitted.

When my mother is moved to a hospital room, I check with the nurse to make sure that the status is now admitted.

Here’s What I Learned

Be persistent. Know these rules so that you can challenge them if appropriate. This discussion must occur in the emergency room. The reason is that when the patient leaves the emergency room, you cannot get the status changed.

Here’s Why I Wrote This

As a long-term care planning specialist and a thought leader in this industry, I feel that I have a responsibility to keep you informed about these types of changes. My mother did go to a skilled nursing facility for physical therapy and rehab following her hospital stay and will probably be there for several weeks. If I hadn’t insisted that her status be changed, we would be charged $650 day for her care.

— Read Long-Distance Caregiving, Up Close: LTCI Insider, on ThinkAdvisor.

Margie Barrie, an agent with ACSIA, has been writing the LTC Insider column since 2000.