Tuesday, June 25, 2013

Facing the Issue: Observation Stays

When it comes to politics, it’s often easy to forget the men and women who are impacted by decisions made in Washington. But at the heart of every issue there are people – lives that are affected by laws, rules, and regulations. So we’re putting faces, names, and stories to the topic at hand. Each of these stories comes from an individual who has voluntarily chosen to become an advocate for this issue by sharing his/her own personal experience.

The Issue: Under the Medicare statute, patients must have an inpatient hospital stay of three or more consecutive days, not counting the day of discharge, in order to meet Medicare criteria for coverage of post-acute care in a SNF. As a result, although the care received by patients in observation status is indistinguishable from the care received by inpatients, outpatients in observation who need follow-up care in a SNF do not qualify for Medicare coverage. Hospital stays classified as observation, no matter how long and no matter the type or number of services provided, are considered outpatient. These hospital stays do not qualify patients for Medicare-covered care in a SNF. Read more about observation stays

Billie Frost
White Oak Manor

South Carolina
When Mrs. Billie Frost entered White Oak Manor, she was coming off of a four-day stay at the hospital. As happens with all incoming patients, Mrs. Frost’s medical discharge papers were reviewed by the receiving staff at the skilled nursing center. According to these documents, Mrs. Frost had been under in-patient status at the hospital. Given that in-patient was recorded on her discharge papers, the skilled nursing center billed her stay at the facility to Medicare. That claim was denied. When White Oak Manor inquired about the denial with the hospital, it was revealed that Mrs. Frost was admitted to the hospital under observation status, but after a case management team reviewed her situation, Mrs. Frost’s status was changed to in-patient for the final two days of her hospital stay. Because her first two days at the hospital were categorized as observation, Mrs. Frost’s Medicare claim was denied on the basis that she did not meet the three-day stay requirement of Medicare.

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