I'm new to the forum this evening. I've been primary caregiver for my 90-year old father for more than two years. I've just come through a nightmare week in which I had to check my father into the hospital (he took a fall at Assisted Living) and then, on Wednesday, place him in skilled nursing. It has been emotionally draining to say the least, but my experience with the hospital was nothing short of horrendous. To make a long story short, he was "checked" into the hospital for 6 days on what is referred to as "observation" status. When it came time for his transfer to skilled nursing, I was informed he would not qualify for Medicare Part A reimbursement for skilled nursing due to the fact he had not been "admitted" to the hospital for three days. He was accepted to skilled nursing only as a "private pay" patient at the rate of $242/day, and I was required to pay upfront for the first 10 days ($2400, I am his POA).

My father is suffering from advanced prostate cancer, underwent surgery in Sept. for a broken hip, and had taken a fall in Assisted Living the morning of 1/30/08. He was taken to the hospital twice (yes, twice!) on Wed. 1/30. The first time, the hospital assured me he was fine and could return to Assisted Living. However, they sent him back to Assisted Living on a stretcher! The Assisted Living folks put him to bed and returned 1-1/2 hrs.later to wake him to eat. When they tried to get him up, he screamed in agony from the pain in his leg. They called 911, and he was returned to the hospital. Asssisted Living called me, and I followed up with a call to the hospital. I spoke with the E.R. nurse who again assured me his x-rays looked fine but, as a precaution, they were admitting him for "observation". I got in touch with his Orthopedist who reviewed the x-rays while we were on the phone and said they were suspicious for a fractured knee. He said my father would need to be admitted for a couple of days while they did a workup. I didn't know at the time that the hospital was going to refuse him formal "admission" and keep him for six days in "observation", thus disqualifying him from his benefits under Medicare Part A.

The folks at skilled nursing were appalled to see a patient in the condition my father was in arrive from the hospital after six days never having been "admitted". What is particularly upsetting is they tell me he really requires a Medicare Part A level of care (he is still in much pain) but will receive only a Medicare Part B level of care due to his "disqualification" for Medicare Part A coverage (despite $242/day out of pocket!).

There is more horror to this story than I've told here. It would take pages. I've been in touch with an attorney at Centers for Medicare Advocacy who tells me this is happening frequently as hospitals and Medicare try to contain costs. He has heard, and they have represented, a number of horror stories like mine. These patients literally "fall through the cracks" of the system in ways I can't begin to describe. I'm wondering if anyone else has encountered this problem and would be willing to share their experience.

Phillygal, are we learning of another way they are using to not pay for provided services.The first thing our hospital does was ask for all this information.Once it is in the computer we never had to give it again.
I hope you can get this resolved.Sadly at the cost of a lawyer.I have met with awful things but never heard of this one.Hope resolution comes quickley.

This is a NEW one to me, too, Mae! My head is spinning.

do caregivers not have enough to be concerned they have to add something new to their list.Mariabee, such an experience would have my tongue going a million miles a minute.I would not be able to control my emotions.I have a reputation for such when I know something is wrong.
Hearing this makes me so mad..By the way, my hear spins all the time.Need to slow it down

PhillyGal, I am truely shocked by this. In the past, the hospital we deal with here has done all in their power to get all the money from medicare and insurances first because they know they will get that. They can never be sure about collecting from an individual so that is a last resort.

If this is some new tactic, we all appreciate the warning. I never heard of "checking in for observation" being different from "being admitted". Thanks for sharing this with us. I hope the attorney will be able to straighten this out.

The true horror of course is your Father's pain and the casual disregard of the hospital in the first place. At least it sounds like the AL is on the ball and he is in the right place for proper care now.

quote:

If this is some new tactic, we all appreciate the warning. I never heard of "checking in for observation" being different from "being admitted

Bobcat, I would like to know the difference also.These hospitals want some guarentee they are getting their money.For reasons you have stated.Someone made a boo boo.Also how can anyone be held responsible if the coreect admission papers were not signed.?

Mae, Bobcat, MariaBee...many, many thanks for your quick responses! I'm pretty much alone in this (getting little support from my siblings), so it's good to know there are folks out there I can talk, and vent, with!

I may need to clarify though. I believe my father's six-day hospital stay in "observation" was covered under Medicare. At least I hope it was! He does have supplemental insurance through railroad retirement which should pick up what Medicare doesn't pay for his time in the hospital.

What's at issue here though is his coverage under Medicare Part A for SNF (skilled nursing facility, I'm learning the lingo!). Medicare requires that a patient be "admitted" to the hospital and spend three nights as an "admitted" patient in the hospital before qualifying for Part A coverage in a SNF.

I don't know how long the hospitals have been making the "admitted" vs. "observation" distinction. (Interestingly, I believe Medicare guidelines allow no more than 48 hours in "observation" which makes our case even more baffling.). Almost everyone I've mentioned this to has never heard of it, so I imagine it's a recent development. And I suspect, as you do, it's another way to deprive people of their rightful benefits and save money for whatever.

As I mentioned, there is more to this story than I was reasonably able to post. It is a nightmare I fear I may never wake up from. The real horror, apart from the suffering it is causing my father, is finding out the extent to which "healthcare professionals" (I'm referring specifically to the Social Services people at this hospital) will go to deceive and defraud the very people they are there to protect, some of them among our most vulnerable!

If the dust ever settles, I intend to get this story out to the media. It is a story people (particularly those caring for our elders) need to hear!


P.S. Does the forum allow the posting of hyperlinks? If anyone's interested, I've found a number of online sites where this "observation" vs. "admitted" issue is outlined and discussed.

Philly Gal, we can only imagine what you are dealing with.You have given others something to research with your problem.
I can assure you, there are people trying to seek answers that may help.I have cared for 3 who have been admitted for observation and never experienced such.Goes to show you how 2 words can determine something.
You seem to be saying , your father was not there long enough to be qualified for part A.Interesting but new to me.Please keep us informed.You have brought to information to us.

Mae: What is so perplexing about this case is that when I reviewed my father's hospital notes with the R.N. at skilled nursing, all indicatons were that he had been "admitted". And it appears his doctors were of that understanding. In fact, his orthopedist told me later that he was unaware the hospital had failed to "admit" him.

There is something questionable, and troubling, going on with this hospital. My father has been a patient there twice (admitted, observed, whatever). Last Sept. he was there for two weeks when he was diagnosed with metastatic prostate cancer and underwent surgery for a broken hip. Both times he was checked into this hospital, he was checked in as an "Observation" (yes, even with a broken hip!). The first time his status was changed to "Admission" when they realized his hip was broken, and they had no choice but to "admit" him. Both times I received calls from Social Services within a day of his check-in, informing me he would likely be "discharged" within 48 hours and would not qualify for Medicare Part A coverage in a SNF, and we would have to "private pay". (I find this curious because I believe 48 hours is the maximum time Medicare allows a hospital to keep a patient under "observation"). And both times, Social Services pushed for his "discharge" within 48 hours, before his tests results were back, and before we knew his diagnosis and prognosis.

But it gets even more fishy. When I called the Records Dept. on Friday to request copies of his file, I was told they had no record in the computer of my father having been a patient there between the dates of 1/31/08 and 2/2/08!!! Was I hallucinating??? He was there, I can attest to it, from 1/30/08 to 2/5/08!!! I suspect they've "cooked the books". It wouldn't surprise me to find out these folks are engaging in racketeering, taking kick-backs for referring elder patients to SNF's as "private pays", along with Medicare fraud. After what I've been through with them, nothing would surprise me.

Does anyone know how to get an investigation launched?

Welcome PhillyGal!
That is the fishiest story I have heard in a looong time!! Since this is fundamentally a Medicare issue (whether fraud, etc.), I would start there and make a complaint. Make a complaint with your state SHIP also. I found some possible resources for you to try...

quote:

• Visit www.medicare.gov on the web.
• Visit the Ombudsman’s webpage at www.cms.hhs.gov/center/ombudsman.asp on the web.
• Call your Quality Improvement Organization if you have a complaint about the quality of Medicare-covered services. A Quality Improvement Organization consists of groups of doctors and health care experts to check on and improve the care given to people with Medicare. Visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get their telephone number. TTY users should call 1-877-486-2048.
• Call your State Health Insurance Assistance Program (SHIP) for help with questions about appeals, buying other insurance, choosing a Medicare health or prescription drug plan, buying a Medigap policy, and Medicare rights and protections. The SHIP program is a State program that gets money from the Federal Government to give free local health insurance counseling to people with Medicare. You can find their telephone number by visiting www.medicare.gov on the web. Under “Search Tools,” select “Find Helpful Phone Numbers and Websites.” Or, call 1-800-MEDICARE (1-800-633-4227) to get their telephone number. TTY users should call 1-877-486-2048. My Health. Medicare.CMS Pub. No. 11173 Revised April 2007

Hope this helps! What WEASELS!!!

Oh yeah... do you still have the hospital ID bracelet they put on him in the hospital? That surely would be "proof" that he was there and also should have some information, number, something that would help them locate him in their "system."

Good luck and go get 'em!!

This message has been edited. Last edited by: Moms_Buddy,

Where I work, Observation is defined as a stay in the hospital of less than 23/24 hours.
If they stay longer, it is indeed an Admission.

I've been in contact with Medicare, and they directed me to Quality Insights, the organization in my state that handles these complaints. I called Quality Insights on Saturday, and they told me to put my concerns in writing and get it to them as quickly as possible.

What boggles the mind though is Quality Insights tells me they handle only the complaints of "admitted" patients and said they may not be able to help me due to the fact my father was never "admitted" to the hospital. He had to be "admitted" to the hospital in order to be "discharged" from the hospital and thus able to file a "discharge" complaint. But my father was "IN" the hospital for 6 days!!! Quality Insights did say they would review the case and direct me to other resources.

So it appears a patient can "enter" the hospital for six days, never be an "admission", only an "observation". A committee at the hospital decides who's an "admission" and who's an "observation". The patient has no right, that I'm aware of, to appeal this decision. Furthermore, upon "discharge" from the hospital, such patient does not have the right to dispute the "discharge" because as an "observation" patient they were never "admitted", and patients who have not been "admitted" cannot be "discharged". So I guess "observation" patients just "go into" the hospital and "get out" of the hospital!! Has the whole healthcare system in this country gone mad!!!!

But here's another twist to the story. Medicare requires the SNF to issue an ABN (Advanced Beneficiary Notice) notifying me of my denial for benefits under Medicare Part A. The SNF issued me an ABN, and it gives me two options (ie., checkboxes).

The first option is to request that the SNF bill Medicare for the "denied" charges. This option gives me the right to file an appeal with Medicare (and also the opportunity to get my case in front of Medicare!).

The second option is an acknowledgement that I know I've been denied benefits under Medicare Part A, and that I accept that decision and waive my right to an appeal. Fine and dandy. Problem is, the SNF already checked off (ie., pre-selected) the second checkbox when they presented me with the form! I called the attorney at Centers for Medicare Advocacy, and he told me that pre-selection of an item on the ABN by a Medicare provider is illegal, period!!! He told me not to sign the form, and I didn't. But the SNF is refusing to send the bills to Medicare!!!!

So how am I going to file an appeal???

Many, many thanks to all of you for listening and responding so quickly. It makes me feel less alone. This case may end up in the Supreme Court, but I sure hope it gets resolved way before that!

This message has been edited. Last edited by: PhillyGal,

DonsWife:
I believe 23/24 hours in observation is the rule in most hospitals. I think Medicare will allow them to stretch it to 48 hours in some cases. Here's a link to the Centers for Medicare Advocacy that describes a similar case: http://www.medicareadvocacy.org/SNF.ObservationStatus.htm.

DUring the hurricane, I was informed that most observation periods are only for 23 hours (?), but that can be extended to 48. I have NEVER heard of observation under Medicare for 6 days!!

quote:

I called the attorney at Centers for Medicare Advocacy, and he told me that pre-selection of an item on the ABN by a Medicare provider is illegal, period!!! He told me not to sign the form, and I didn't. But the SNF is refusing to send the bills to Medicare!!!!

So how am I going to file an appeal???

I would call that attorney right back and put that question to him! There is something TERRIBLY not right with all of this, so get all the advice that you can. I LOVE the Catch 22 that the Quality Insights (what a misnomer, eh?) people related to you...

What about your state hospital regulatory agency? Seems like a complaint could be lodged with them, also...