admitted-for-observation-medicareA few weeks ago, I wrote about how Affordable Care Act has affected Medicare. In researching this topic, I initially went straight to the horse’s mouth and asked seniors about the changes they had noticed thus far. Most of the folks I asked hadn’t noticed anything much beyond their annual wellness exam now being covered by Medicare at 100 percent, which of course, they were happy about.

But two of the seniors had heard some information through the grapevine that they didn’t make them so happy. Essentially, the word on the street was if you were hospitalized for observation, Medicare wouldn’t pay. That could mean beaucoup bucks! Fearful of this prospect, one woman apparently had even signed herself out of the hospital to avoid it.

I asked Healthcare Solutions Connection principal, Rebecca Gwilt, who provides legal and consulting services to healthcare providers, if this second-hand information had any basis in truth. Here’s how she explained it to me:

When you seek services from a hospital, you have to be “admitted” for Medicare to cover your care under Part A (the hospital benefit). If you’re not admitted, you’re an outpatient and considered under observation care, which is covered under Part B. In that case, all related copayments apply. Makes sense so far, right?

Where it gets fuzzy is you can actually be in the hospital, even for a few days, and not be technically “admitted.” Hospitals are becoming more and more careful about who they “admit” because they’re now subject to penalties by the Centers for Medicare and Medicaid Services if they admit patients that don’t meet certain criteria.

As if that’s not nebulous enough, hospitals aren’t even required to tell you whether you’ve been admitted, so you may not know whether your care has been covered or not until you receive the bill. Plus, if you’re discharged to a nursing home without being an admitted hospital patient, you won’t qualify for Medicare Part A in this setting either (you must be an admitted hospital patient for three consecutive days to qualify).

These days, it’s the patient’s responsibility to take responsibility for his or her own care. While Gwilt strongly advises that you ask whether you’re being admitted and make any further care decisions based on that knowledge, there is a Medicare appeals process if you think you should be covered as an inpatient.