By William K. Alcorn
U.S. Sen. Sherrod Brown was in town to tout a bipartisan plan that would change a little-known Medicare rule that causes seniors to be unexpectedly hit with large costs for necessary post-acute medical care.
Brown, D-Avon, speaking Friday at St. Elizabeth Health Center, said that under current Medicare policy, enacted Oct. 1, 2013, a beneficiary must have an “inpatient” hospital stay of at least three days for Medicare to cover post-hospitalization skilled nursing care.
Patients who receive hospital care on “observation status” do not qualify for this benefit, even if their hospital stay lasts longer than three days. They also can be billed by the hospital for the difference in reimbursement it receives for inpatients and those on observation status.
“When seniors are transferred from a hospital to a nursing home for further care, they should be able to focus on their recovery instead of technicalities that could lead to sky-high medical bills,” Brown said.
Brown’s bill, the “Improving Access to Medicare Coverage Act,” would amend Medicare law to count a beneficiary’s time spent in the hospital on observation status toward the three-day hospital stay requirement for skilled nursing care. It also would establish a 90-day appeal period after passage for those who have a qualifying hospital stay and have been denied skilled nursing care after Jan. 1, 2013.
In the interim, Medicare patients should heed the advice of Mary Beth McKnight Potts of Youngstown, who has been a registered nurse for 40 years, the last 30 at ValleyCare Northside Medical Center.
McKnight Potts told the story of her aunt, Frances Necko of Austintown, who has been undergoing treatment for a rare form of Parkinson’s disease and recently had a 10-day hospital stay.
Shortly after being discharged, Necko still experienced difficulty and needed additional care. She was terrified, however, of returning to the hospital and being put under observation status and having to pay medical bills she couldn’t afford, McKnight Potts said.
“We sifted through the paperwork and approached her physician about admitting my aunt as an inpatient. That first 24 hours of observation can trip you up,” she said.
McKnight Potts advised seniors to touch base with case managers at their acute-care hospital to help ensure they are eligible for coverage for medications and care after they leave the hospital and enter a skilled-care setting.
According to the Centers for Medicare and Medicaid Services, outpatient classification is intended for providers to run tests and evaluate patients in order to arrive at appropriate diagnoses and treatment plans, or to provide brief episodes of treatment.
Typical services that are not considered “inpatient” involve emergency department services, outpatient surgery, lab testing, or X-rays.
For the purposes of counting inpatient days, CMS considers a person an inpatient the first day the patient is formally admitted to the hospital because of a doctor’s order; the last day is the day before discharge.
Brown was joined by Donald Koenig, executive vice president of Humility of Mary Health Partners, and George Semer, director of care coordination for HMHP. HMHP operates St. Elizabeth.
Koenig, who described the problem as “unintentional consequences of a well-intentioned rule,” supported Brown’s proposal.
Under the new CMS rule, doctors are asked to quickly determine if a patient will be under observation status and document if the patient will be an inpatient, he said.
Traditionally, the observation period was 24 to 48 hours, for which the hospital is paid less than for inpatients, even though the care is the same.
The problem for the patient is that unless they are admitted for at least three days, Medicare won’t pay for further lower-level care, Koenig said.
“Let’s do what is right for patients, which is the right care setting at the right time” and covered by Medicare, he said.
Semer said Brown’s proposed legislation would help ease the transition from acute care to a lower level of care.
“The three-day stay requirement should be eliminated ... the sooner the better,” he added.
Brown said he would like to fix the Medicare glitch without legislation by asking Medicare to simply change its policy.
Brown said that if the change occurs, it would cost the taxpayer money, but how much has not been determined. He said that information has been requested.