I am a UM/UR Nurse so thanks for educating the people as this is a huge part of of my job. Unfortunately you would be surprised as many of the physicians don’t know any of this as well. I am also a former SNF Administrator before becoming a RN so while I did not learn anything new I will definitely be sharing your video as it was a great presentation and easy to understand. BTW I have lost one appeal in 16 years. If I even get a whiff of an appeal I review that case and I am on that physician like like they are in an IRS audit. That said if the patient doesn’t need an admission I will have that NONC letter written in a few minutes, I even come in on the weekends. I have to personally call the CEO of our hospital system if a doc tries to admit a patient who does not meet acute criteria. She is great to me but others... not so much. I am always a huge advocate of getting patient what they need regardless of their payor source but not what they want ie a medically unneeded qualifying stay. BTW the qualifying stay is waived right now by CMS due to COVID thankfully. Hope it stays waived. Great video.
We're so happy to hear that our video will help educate people as you pass it around. It is such a confusing topic that so many get wrong too often. Thank you for the work you do.
I'd be interested in seeing a video that speaks to going from and incident that places one in the ICU and then an Acute Care Hospital. What Medicare pays for, co-payments, limits on days, etc.
Great job explaining this complicated, yet important, potentially costly part of Medicare. What happens if you are admitted as inpatient for knee replacement surgery, are discharged in 2 days and they, after the fact, write you at home to say they are changing your status to observation/outpatient? 1) Is that ethical to do that under those circumstances just to bill Medicare potentially more under part B? 2) And What is your responsibility to Medicare as the patient? Is it fraud? 3) Finally, what if there were post surgical complications that necessitated rehab? Would Medicare cover it without the three days inpatient? In hindsight it sounds like it could have been a big problem.
Boomer Benefits Happened to my neighbor who was worried, showed me the letter and asked me about it. A call to the billing office confirmed it was done bc they could collect more from Medicare and her F plan. THEY may not pay more but Medicare will. Luckily he didn't need rehab and is fine, but we wonder why our premiums go up every year?! Grrrrr
@@lyndayoung8761 We looked into this a little and found this: When a physician orders an inpatient admission, but the hospital's utilization review committee determines that the level of care does not meet admission criteria, the hospital may change the status to outpatient only when certain criteria are met. Criteria : The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital; The hospital has not submitted a claim to Medicare for the inpatient admission; A physician concurs with the utilization review committee's decision; and The physician's concurrence with the utilization review committee's decision is documented in the patient's medical record.
@@BoomerBenefits Thank you for the research. Some of it including the part about "before discharge" which wasn't done was in the letter. I am hoping she will share his MSN with me so I can learn more about this. Thank you Danielle, you're the best.
I have a Kaiser senior advantage plan. This plan does not require a three day admitted stay in the hospital before the stay in a skilled nursing facility is cost free for up to 20 days. I know you prefer medigap plans but Kaiser and several other advantage plans do not have the 3 day hospital admittance rule.
Let’s say a patient is admitted to the hospital. They don’t meet inpatient criteria for whatever the Doc lists as diagnosis, but states that pt is expected to need more than two midnights of care because whatever they list as reasons. What is the correct status in this situation?
You're an inpatient when the hospital formally admits you with a doctor's order. However, you can be held under Medicare Part B observation while in the hospital. If you are under observation for more than 24 hours, you must be given a Medicare Outpatient Observation Notice and it tells you why you are considered as outpatient rather than inpatient. PT is also considered to be a Medicare Part B outpatient service, so it is likely this person will have all services fall under Part B.
The doctor would prefer all patients to be considered in-patient, but there are rules from the insurers on what medical conditions can even be considered for in-patient admission. A patient cannot just ask the doctor or hospital to admit to in-patient. In-patient admissions without in-patient criteria would be considered fraud.
Thanks for this video. As I understand it, one must spend three midnights after being admitted as an inpatient in the hospital before Medicare will covered skilled nursing, either as someone new to skilled nursing or someone who has been receiving long-term nursing care who needed to go to the hospital and will be returning to the same after discharge from the hospital. Is what I've said about the three midnights correct?
Yes, you must have an inpatient stay of at least 3 days before Medicare will cover SNF care. However, Medicare doesn't cover long term care. So after the person receiving Long-term gets their recovery care from their hospital stay, Medicare won't cover the stay after 100 days.
@@BoomerBenefits Thanks. I'm aware of the second part--Medicare will cover100% the first 20 days of long term care if progress (such as rehabilitation) is taking place, and then a co-pay is required for the next 80 days, and then it quits. When my mother quit her physical therapy, she essentially threw away ~$16K that Medicare would have paid (and she was private pay!); I didn't have the heart to tell her. Fortunately, the upswing in the stock market more than made up for it.
Let me see if I understand what you said. If admitted to the hosp. Part A should cover XRay? What if the XRAY was done in ER then you were admitted, does Part A still cover it?
Actually, as an inpatient, Part A covers your room, meals, some medications, and a few other things, while Part B is still in charge of your doctor services and tests, such as an X-ray.
Thanks fir all. I still confused as my husband was in an observation patient two weeks ago, now in rehab two weeks until today.( concussion spinal ) is Medicare going to cover expenses? Thanks for your time.
We cannot tell you with 100% certainty if Medicare will cover a service. However, if his services are deemed medically-necessary and coded correctly, then Medicare should provide coverage. Be sure to check out our video, Will Medicare Cover My Procedure? What's Covered by Medicare
Observation status typically becomes BEFORE you are admitted. Once you are admitted, you are then considered an inpatient. It is completely up to the doctor's discretion whether you should be discharged or must stay longer.
No. When you have an MAPD plan, Part A and Part B don't pay for anything and you won't pay any other their cost-sharing expenses. When you have an MAPD plan, you agree to have that insurance carrier cover you and you abide pay their cost-sharing rules - very much like an under 65 policy you would get through an employer.
It depends on your Medigap plan, but if you have a Medigap plan that covers the Part B coinsurance at 100%, then yes. boomerbenefits.com/medicare-supplemental-insurance/medigap-comparison-chart/
Does the doctor make more money because of this decision? If you tell the doctor you prefer to be admitted because of your Medicare out of pocket, will they say OK?
They may say okay. But if they say no, they have to provide you with a written letter as to why they don't believe you need to be admitted. In the end, if you have a comprehensive Medigap plan, like Plan G, your costs will be low either way.
Medicare has very specific criteria for admission. The doctor must follow them. If the doctor admits a patient as inpatient status when the patient did not meet inpatient criteria per Medicare guidelines, the hospital could get flagged by Medicare to be audited which any hospital does not want. Doctors are very aware of these rules. Yes, by law patient must be notified and sign appropriate paperwork to say they understand they are in outpatient status and not inpatient.
No the physician does not make more Money directly based on Observation or inpatient status of the patient, see CFR 42 482.30 Utilization review. The DRG, ICD 10 code, Coder, UM nurse and your physicians documentation all play a role in payment but in many cases now the hospitalists are paid a salary and for doing the correct thing. This means incentives or bonuses for supporting obs or inpatient based on the patients objective needs only.
I am a UM/UR Nurse so thanks for educating the people as this is a huge part of of my job. Unfortunately you would be surprised as many of the physicians don’t know any of this as well. I am also a former SNF Administrator before becoming a RN so while I did not learn anything new I will definitely be sharing your video as it was a great presentation and easy to understand. BTW I have lost one appeal in 16 years. If I even get a whiff of an appeal I review that case and I am on that physician like like they are in an IRS audit. That said if the patient doesn’t need an admission I will have that NONC letter written in a few minutes, I even come in on the weekends. I have to personally call the CEO of our hospital system if a doc tries to admit a patient who does not meet acute criteria. She is great to me but others... not so much. I am always a huge advocate of getting patient what they need regardless of their payor source but not what they want ie a medically unneeded qualifying stay. BTW the qualifying stay is waived right now by CMS due to COVID thankfully. Hope it stays waived. Great video.
We're so happy to hear that our video will help educate people as you pass it around. It is such a confusing topic that so many get wrong too often. Thank you for the work you do.
I'd be interested in seeing a video that speaks to going from and incident that places one in the ICU and then an Acute Care Hospital. What Medicare pays for, co-payments, limits on days, etc.
God bless you thank you for all you do.
Great job explaining this complicated, yet important, potentially costly part of Medicare.
What happens if you are admitted as inpatient for knee replacement surgery, are discharged in 2 days and they, after the fact, write you at home to say they are changing your status to observation/outpatient?
1) Is that ethical to do that under those circumstances just to bill Medicare potentially more under part B?
2) And What is your responsibility to Medicare as the patient? Is it fraud?
3) Finally, what if there were post surgical complications that necessitated rehab? Would Medicare cover it without the three days inpatient? In hindsight it sounds like it could have been a big problem.
Has this actually happened to you?
Boomer Benefits
Happened to my neighbor who was worried, showed me the letter and asked me about it. A call to the billing office confirmed it was done bc they could collect more from Medicare and her F plan. THEY may not pay more but Medicare will. Luckily he didn't need rehab and is fine, but we wonder why our premiums go up every year?! Grrrrr
@@lyndayoung8761 That's crazy. Well, fortunate enough, your friend has Plan F so they won't have to worry about extra charges coming their way.
@@lyndayoung8761 We looked into this a little and found this: When a physician orders an inpatient admission, but the hospital's utilization review committee determines that the level of care does not meet admission criteria, the hospital may change the status to outpatient only when certain criteria are met.
Criteria
:
The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital;
The hospital has not submitted a claim to Medicare for the inpatient admission;
A physician concurs with the utilization review committee's decision; and
The physician's concurrence with the utilization review committee's decision is documented in the patient's medical record.
@@BoomerBenefits Thank you for the research. Some of it including the part about "before discharge" which wasn't done was in the letter. I am hoping she will share his MSN with me so I can learn more about this. Thank you Danielle, you're the best.
thank you again and again and again! youre so bright! ...
I have a Kaiser senior advantage plan. This plan does not require a three day admitted stay in the hospital before the stay in a skilled nursing facility is cost free for up to 20 days. I know you prefer medigap plans but Kaiser and several other advantage plans do not have the 3 day hospital admittance rule.
Medicare Advantage plans play by their own rules. This video discusses Original Medicare's coverage.
Let’s say a patient is admitted to the hospital. They don’t meet inpatient criteria for whatever the Doc lists as diagnosis, but states that pt is expected to need more than two midnights of care because whatever they list as reasons.
What is the correct status in this situation?
You're an inpatient when the hospital formally admits you with a doctor's order. However, you can be held under Medicare Part B observation while in the hospital. If you are under observation for more than 24 hours, you must be given a Medicare Outpatient Observation Notice and it tells you why you are considered as outpatient rather than inpatient. PT is also considered to be a Medicare Part B outpatient service, so it is likely this person will have all services fall under Part B.
The doctor would prefer all patients to be considered in-patient, but there are rules from the insurers on what medical conditions can even be considered for in-patient admission. A patient cannot just ask the doctor or hospital to admit to in-patient. In-patient admissions without in-patient criteria would be considered fraud.
Thanks for this video. As I understand it, one must spend three midnights after being admitted as an inpatient in the hospital before Medicare will covered skilled nursing, either as someone new to skilled nursing or someone who has been receiving long-term nursing care who needed to go to the hospital and will be returning to the same after discharge from the hospital.
Is what I've said about the three midnights correct?
Yes, you must have an inpatient stay of at least 3 days before Medicare will cover SNF care. However, Medicare doesn't cover long term care. So after the person receiving Long-term gets their recovery care from their hospital stay, Medicare won't cover the stay after 100 days.
@@BoomerBenefits Thanks. I'm aware of the second part--Medicare will cover100% the first 20 days of long term care if progress (such as rehabilitation) is taking place, and then a co-pay is required for the next 80 days, and then it quits.
When my mother quit her physical therapy, she essentially threw away ~$16K that Medicare would have paid (and she was private pay!); I didn't have the heart to tell her. Fortunately, the upswing in the stock market more than made up for it.
Are there any liabilities if you refuse observation admittance?
Let me see if I understand what you said. If admitted to the hosp. Part A should cover XRay? What if the XRAY was done in ER then you were admitted, does Part A still cover it?
Actually, as an inpatient, Part A covers your room, meals, some medications, and a few other things, while Part B is still in charge of your doctor services and tests, such as an X-ray.
@@BoomerBenefits thank you
Thanks fir all. I still confused as my husband was in an observation patient two weeks ago, now in rehab two weeks until today.( concussion spinal ) is Medicare going to cover expenses? Thanks for your time.
We cannot tell you with 100% certainty if Medicare will cover a service. However, if his services are deemed medically-necessary and coded correctly, then Medicare should provide coverage.
Be sure to check out our video, Will Medicare Cover My Procedure? What's Covered by Medicare
Once a patient is formally admitted to acute, can he or she go back to an observation status?
Observation status typically becomes BEFORE you are admitted. Once you are admitted, you are then considered an inpatient. It is completely up to the doctor's discretion whether you should be discharged or must stay longer.
On an MAPD if the patient is getting an inpatient surgical procedure done, do they pay the part A deductible PLUS 20% for the cost of the surgery?
No. When you have an MAPD plan, Part A and Part B don't pay for anything and you won't pay any other their cost-sharing expenses. When you have an MAPD plan, you agree to have that insurance carrier cover you and you abide pay their cost-sharing rules - very much like an under 65 policy you would get through an employer.
If observation status covers 80%
does a Medigap plan pick up the rest?
It depends on your Medigap plan, but if you have a Medigap plan that covers the Part B coinsurance at 100%, then yes. boomerbenefits.com/medicare-supplemental-insurance/medigap-comparison-chart/
Does the doctor make more money because of this decision?
If you tell the doctor you prefer to be admitted because of your Medicare out of pocket, will they say OK?
They may say okay. But if they say no, they have to provide you with a written letter as to why they don't believe you need to be admitted.
In the end, if you have a comprehensive Medigap plan, like Plan G, your costs will be low either way.
@@BoomerBenefits Thanks. I am going to further investigate this process.
Medicare has very specific criteria for admission. The doctor must follow them. If the doctor admits a patient as inpatient status when the patient did not meet inpatient criteria per Medicare guidelines, the hospital could get flagged by Medicare to be audited which any hospital does not want. Doctors are very aware of these rules. Yes, by law patient must be notified and sign appropriate paperwork to say they understand they are in outpatient status and not inpatient.
No the physician does not make more Money directly based on Observation or inpatient status of the patient, see CFR 42 482.30 Utilization review. The DRG, ICD 10 code, Coder, UM nurse and your physicians documentation all play a role in payment but in many cases now the hospitalists are paid a salary and for doing the correct thing. This means incentives or bonuses for supporting obs or inpatient based on the patients objective needs only.