Hospital admission...

[imoldernu]

Here's a theoretical... you supply the answer...

1. John becomes very physically ill. Fearing death, call to 911 and John goes to emergency room.

2. After basic series of tests, John does not test positive, but still feels physically ill and asks to be admitted to the Hospital for a period of observation, and for fear of even worse symptoms, and a worsening of the problem.

Can/will the hospital accept his request?

Maybe not as simple as you'd believe... especially with rooms costs that, by state, average from about $400 to over $2600/ day.

And along the same lines... simple question... are "for profit" hospital room rates higher or lower than "not for profit" room rates?


You thought you knew about health costs....

 

[Senator]

If he is paying the bill himself, and can prove he has thr assets to do it, I would think so.

If insurance is paying, I would suspect that they would say it is not approved. You cannot just use a hospital as a motel.

 

[ERhoosier]

Agree with Senator. Most insurance plans (inc Medicare & Medicaid) have developed rather specific criteria for hospital admission. Indeed FAR too $$$$ to use bedspace as hotel room. And where beds are in critically short supply, I doubt hospitals would let you electively pay out-of-pocket even if you had the ready cash.

From what I've read, hospital room rates vary widely. Some of that variance depends upon what is (or is not) included in the base charge. "For profit" facilities may charge more or less $$ than "not for profit". Keep in mind that "not for profit" does not mean employees cannot make big $$$$- just that the organization's bank account needs to be empty at year end when Uncle Sam checks

 

[easysurfer]

If John is on Medicare and gets admitted he wants to make sure the stay is coded as inpatient and not for observation. The coding was in the news a few months back that a wrong code could cost big $$$.

 

[Texas Proud]

If John is on Medicare and gets admitted he wants to make sure the stay is coded as inpatient and not for observation. The coding was in the news a few months back that a wrong code could cost big $$$.

This is what I was thinking... being admitted for 'observation' I think would be on his dime... so why not let him be 'observed'....

 

[imoldernu]

Wasn't trying to be cute with the question, but just encountered the same situation described in the OP, and thought it important enough to mention the unexpected answer. In our case, the hospital refused admission to a hospital bed because of the details mentioned in the article. (see link below)

The hospital performed diagnostic tests that were negative. Despite the fact that the symptoms of the illness remained, failure of the emergency room testing to find the problem, resulted in the refusal, even with the agreement to pay costs that would not be covered by insurance. The maximum time allowed by the regulations is 23 hours. The legal aspects were discussed in some detail, before the refusal.

The caveat that would seem to allow a pass... (the Patient's Doctor's approval) fell under the same legal ruling. There was an attempt made to go for additional tests... blood analysis, Xrays, and a Cat Scan... 6 hours of testing and analysis, which might have given the hospital grounds for admittance, but despite this there were no legal means to get approval.

Yeah... I know... "my doctor would never allow this to happen"... and that's what I thought.
................................
By the way... even if this seems like a situation that could never happen, reading the article will give some insights as to what to do in situations such as traveling outside your residential area.
The article also points up some anomalies having to do with 911 Ambulance protocol as well as some prior planned preparations for having basic information on medications, health history, contacts, insurance, situational incidents, recent meals, activities, allergies etc, etc.

None of us plan for, or look forward to these issues, but the emergency or time of hospital needs, is not usually the best time to search through papers.

Here's the article:
Hospital Admissions: Read About the Admission Process
It's very long... 15 pages. Pages 4 ad 5 deal with the complexities mentioned above.

And about the average per day stay cost in your state... check this out..
Average Cost Per Inpatient Day Across 50 States in 2010

Boring stuff, until it happens to you...

 

[imoldernu]

A last word on this, only because I have spoken to a hospital administrator, who cleared up the question about why the hospital would not allow transfer from the emergency room to a regular hospital room....
"even if the patient agrees to pay, and even if the hospital has empty rooms"

It has to do with medicare requirements placed on the hospital. By allowing a paying patient in, the hospital would be in violation of the "non discriminatory regulations" (my simple interpretation) that the hospital is required to follow in order to be Medicare approved. ie. having resources to pay cannot supercede the rights to care.

The other reason for posting this, is that the administrator told me that this is not well understood by the public, and that it happens frequently. It just doesn't hit the headlines.

Even your own doctor, if Medicare approved) is bound by these rules, and subject to discipline if found to be prescribing hospitalization without the required preconditions.

Many Hospitals do not affliliate with medicare.

http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2013/10/30/top-hospitals-opt-out-of-obamacare

"In many cases, consumers are shopping blind when it comes to what doctors and hospitals are included in their Obamacare exchange plans," said Josh Archambault, senior fellow with the think tank Foundation for Government Accountability. "These patients will be in for a rude awakening once they need care, and get stuck with a big bill for going out-of-network without realizing it."

"Invincibility is given to a precious few" ~ imoldernu

 

[omni550]

I have had very little personal experience with hospitals.

Q.: If one needs hospital care (presumably this means that they are experiencing something serious health-wise), how does one figure out whether it is in-network or not?

omni

 

[imoldernu]

I have had very little personal experience with hospitals.

Q.: If one needs hospital care (presumably this means that they are experiencing something serious health-wise), how does one figure out whether it is in-network or not?

omni

Good question. This article gives an excellent explanation, and I would suggest that anyone who isn't absolutely sure of their healthcare provider contract, spend the time to look up the details.
In-Network vs. Out-of-Network Care

I'll add a little story from 20 years ago, that happened to us. A veritable nightmare.

DW and I were vacationing in Florida, when she suffered a stroke. At the hospital, it was determined that she had a carotid artery blockage which would require immediate surgery.
At the time, we had our health plan with an HMO in the Chicago area. Prior to going in for the surgery... (best doctor in the southeast), he called our HMO doctor for permission to operate as we were then out of the approved area.
While this should have been a no brainer... emergency... our HMO doctor was conveniently unavailable for approval. I had to sign a "responsibility" document in order for the operation to proceed.
I expected that this would be just a technicality, and that the nature of the emergency would be recognized and of course the bills would be paid. Also , of course, there would be a recovery period in the hospital... again, refused, with the suggestion that she should go back to an approved facility in Illinois.
How?... The HMO suggested a medivac flight... again at my expense.. The estimated cost was $26,000. Of course I refused, and DW's recovery was in the Florida Hospital. Who cares about money at a time like this.

Still, I expected that it would all be straightened out. It was not to be... We received bills totaling more than $120,000... (and that was more than 20 years ago)

It took days of calling back and forth, letters to the governing body of the hospital, affidavits from the surgeon, appeals to the patient advocate organization and many sleepless nights... (we had just recently retired)... to finally get approval.

So... yeah. Thing like this can't happen, but they do. We were simple and trusting, and the $8000/year in HMO charges... plus the wonderful "caring" part of their advertising, had given us a feeling of security. Who would read the page three note about out of plan services, in a document that was twenty pages long?

The world is more sophisticated now... healthcare is better understood by many, and warnings about legal limits of responsibility are more in the news.
Still, surprises are common, and with a tightening of the legal rights provide more loopholes for providers to avoid paying.
.....................................................................................
Sadly, healthcare is only one of the legal contracts we sign for services, that we don't read because of the length and the small type. The simple recap that comes as a cover letter hides the details. for instance, our Comcast agreement is a 24,000+ word legal document. In many cases, not much we can do about this, since we need the services... phone, house insurance, vehicle insurance, life insurance, and things like roofing guarantees, or service contracts....

It's the rock and a hard place. Impossible to live our lives sitting at a desk, using a magnifying glass to read words that we may not even understand.

And so it goes....

 

[omni550]

Thanks, imoldernu for the link and for sharing that terrible situation you found yourself in. Scary.

I, like many here, like to travel. (For example, at the moment, I am spending a month ~1400 miles from home.)

I'm wondering what "travelers" can do proactively to minimize medical costs when traveling (or temporarily residing elsewhere) domestically and internationally? If I'm caught in an critical/emergency situation, I may not remember (or may not be in a position to be able) to ask for in-network providers.

omni

 

[ERhoosier]

A last word on this, only because I have spoken to a hospital administrator, who cleared up the question about why the hospital would not allow transfer from the emergency room to a regular hospital room....
"even if the patient agrees to pay, and even if the hospital has empty rooms"

It has to do with medicare requirements placed on the hospital. By allowing a paying patient in, the hospital would be in violation of the "non discriminatory regulations" (my simple interpretation) that the hospital is required to follow in order to be Medicare approved. ie. having resources to pay cannot supercede the rights to care.

The other reason for posting this, is that the administrator told me that this is not well understood by the public, and that it happens frequently. It just doesn't hit the headlines.

Even your own doctor, if Medicare approved) is bound by these rules, and subject to discipline if found to be prescribing hospitalization without the required preconditions.

Many Hospitals do not affliliate with medicare.

Beyond just a doctor's order, MC, as well as private carriers, have rules regarding payment for hospital admission. It must be "medically necessary" as they define it or payment can be denied (or not covered service). Hospital admission under Medicare (MC) is becoming more complex all the time with new rules and "clarifications" being issued regularly. IOW- Things change a lot over time.
Hospital Center - Centers for Medicare & Medicaid Services
http://www.cms.gov/Medicare/Medicar...loads/IP-Certification-and-Order-09-05-13.pdf
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c02.pdf

And now with MC's new "2-night" rule for defining hospital admissions (vs observation status), more MC patients are being socked with big unexpected bills.
FAQ: Hospital Observation Care Can Be Costly For Medicare Patients - Kaiser Health News

BTW- It is NOT generally illegal to pay for services MC disallows (i.e. says are not medically necessary). There are many lists of "non-covered" services which folks can and do pay for on their own.
What's not covered by Part A & Part B? | Medicare.gov
http://www.cms.gov/Outreach-and-Edu...t_Covered_Under_Medicare_BookletICN906765.pdf
IIUC, it is legal, although perhaps costly, for a physician to admit a patient on MC for non-covered reasons. For example a plastic surgeon admitting a MC patient after extensive cosmetic (non-covered) surgery.

 

[Rickt]

I have just had an experience with hospitalization when I went to emergency room at our local county hospital with complaints of chest pains. After the usual tests--- EKG etc. they decided within 1/2 hour to transfer me to the major university hospital (located 30 minutes away) via ambulance. Within 6 hours of being admitted into ICU and after necessary tests a heart condition was ruled out but the doctors wanted to do a few more tests before they could decided to discharge me. I asked them to move me out of ICU and even though they agreed that I did not need to be in ICU, the hospital was full and there were no beds available on the general floor for them to move me to.

After two days in ICU and several tests (cardiac & GI) they decided that I needed a gall bladder surgery which was performed and I have recently been discharged from the hospital after a total of four night hospital stay (2 days in ICU and 2 days in regular room). Have follow up appointments next week for post surgical follow up.

Both the hospitals involved are in the provider care network of my PPO plan and I have yet to receive bills from the providers. Will gladly share my experience after I receive the bills. Thanks,

 

[MRG]

Rickt,

Glad they figured it out, interesting symptoms. At least very different than my G.B. issues.

I'm sure they told you about some issues you may have postoperative. I lost 35 lbs(needed to) over the first 15 months. I recall smelling salami on a deli plate at least 75' away and becoming ill. Other folks I've known had no issues like I did.

Be very interested if you encounter any surprises on the billing side. My one hospital stay this year no surprises.

Sent from my SAMSUNG-SGH-I337 using Early Retirement Forum mobile app

 

[gayl]

Hospitals & HMOs can be difficult to deal with. Tested positive 6/26, 1st colonoscopy in GE clinic 7/7 multiple cites ruled stage 1 & 2 (10 miles from home), 2nd colonoscopy 7/23 in OR with partial colonectomy (30 miles from home), STILL waiting next steps. With Lynch syndrome in family (I'm the last to get colon CA & 2 confirmed by genetic testing) and everyone stating from 6/26 that partial colonectomy was likely (!) Why did I have 2 procedures & have to travel 30 miles HMO

 

[modhatter]

I can't help wondering the actual reason behind non-profits costing more. I looked them up, and did not see anything spectacular in the way of reputation of the 50 largest. Any doctors or administrators have any insight?

Of course larger salaries, but what about other costs and why higher for non-profit?

 

[ERhoosier]

I can't help wondering the actual reason behind non-profits costing more. ....

I suspect that some not-for-profits are simply more efficient than others. Just like in any other business or charity, waste can be a huge part of total overhead

 

[Texas Proud]

I can't help wondering the actual reason behind non-profits costing more. I looked them up, and did not see anything spectacular in the way of reputation of the 50 largest. Any doctors or administrators have any insight?

Of course larger salaries, but what about other costs and why higher for non-profit?

I will give my normal soundbite....
Most people refer to them as 'non-profits', but in reality they are 'tax exempt' under 501(c)(3)... the tax code never says they cannot make a profit... just that the profits cannot go to an individual...even though there is a lot of places that refer to them and NPOs...

I have a sister who works for one and they make over $100 million a year...