Medicare benefits for “Observation” verses “Admission” to the hospital.

For some time now there has been confusion and even complete surprise to Medicare beneficiaries when they learn that although they spent time overnight in the hospital (perhaps even several overnights) they may not have been ‘admitted’ to the hospital and therefore they are not eligible to receive certain Medicare benefits that are conditional to a qualifying hospital stay.

A doctor may write orders for the Medicare recipient to receive “observation services” in the hospital as a means of determining whether that person should be formally admitted to the hospital or discharged. The physician utilizes guidelines set forth by Medicare to deem whether a stay is categorized as “observation services’ or “hospital admission”. Observations services can be ordered for a period of hours or even for a number of days and is considered an ‘outpatient’ status. As such, if the person is in the hospital under “observation services” this time is not included in meeting the 3-day inpatient hospital stay required to have Medicare coverage for other services like those in a Skilled Nursing Facility (SNF).  Additionally, the status under which one stays at the hospital (observation services or admission) will directly affect whether Medicare Part A  or Part B pays for the stay in the hospital.

Many people are not aware that they must be sure to ask and clarify with the hospital about whether their stay is considered “observation” or “admission”.  If a person is in the hospital under observation status and is then admitted by the physician to the hospital, it will be improtant to ascertain how many nights were spent in each category to fully understand what other benefits may/will be affected.

The services of a Geriatric Care Manager can assist clients through advocacy to understand benefits and challenges that can be experienced with hospital stays.  Matrix Advocare Network  provides care management and client advocacy services throughout the Twin Cities metro area.  For more information about Medicare benefits see www.medicare.gov

Posted in Caregiver Support, Geriatric Care Manager, Health Care Advocate, Nursing Care Management

Leave a Reply

Your email address will not be published. Required fields are marked *

*

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>