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Hospital bill for 25k not covered by Medicare
Old 12-20-2019, 03:34 PM   #1
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Hospital bill for 25k not covered by Medicare

This is something I hadn't heard of before. Somebody has a radical prostatectomy with two nights in hospital and Medicare didn't cover it because he wasn't "admitted".

Opinion: I’m on Medicare, but I still got stuck with a $25,000 hospital bill

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Old 12-20-2019, 03:47 PM   #2
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Sounds like a loophole, he doesn’t mention if he had supplemental insurance.
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Old 12-20-2019, 03:51 PM   #3
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Sounds like a loophole, he doesn’t mention if he had supplemental insurance.
Doesn't supplemental insurance only apply for those charges Medicare deems acceptable?
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Old 12-20-2019, 03:52 PM   #4
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Doesn't supplemental insurance only apply for those charges Medicare deems acceptable?
Yes. Medigap wouldn't help here.
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Old 12-20-2019, 03:52 PM   #5
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They observed his cancer away? I don't think so. Something must be done about the observation status. Who would have ever thought surgery on a cancer would not be covered on a whim of a hospital admitting clerk?
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Old 12-20-2019, 03:54 PM   #6
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They observed his cancer away? I don't think so. Something must be done about the observation status. Who would have ever thought surgery on a cancer would not be covered on a whim of a hospital admitting clerk?
Not a whim at all. By classifying it as “observation” the hospital can charge a higher rate and demand payment. This is deliberate, and IMHO abusive.
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Old 12-20-2019, 03:59 PM   #7
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Article states the patient was covered by Medicare part A, but did not have part B. Would that make a difference?
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Old 12-20-2019, 03:59 PM   #8
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I don't remember how it worked the last time I had an elective but don't they figure out all the financial stuff ahead of time? Ie is it covered by insurance etc? What the copay etc?
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Old 12-20-2019, 04:05 PM   #9
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Article states the patient was covered by Medicare part A, but did not have part B. Would that make a difference?
He had private insurance which probably covers the expense, but the total cost will be higher and he will pay a much higher % of that vs a Medicare B copay.
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Old 12-20-2019, 04:27 PM   #10
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Could this "observation" strategy be something hospitals might try only on the patients they think might have the ability to pay the bill outright?

I can't see any logic in hospitals using this for most Medicare patients in a similar situation. While this guy had some private insurance and likely was financially able to pay, most Medicare patients don't have the ability to do so. The end result in most situations is the hospital would end up with even less $ than what Medicare will pay, so it would be a losing proposition.
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Old 12-20-2019, 04:31 PM   #11
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Could this "observation" strategy be something hospitals might try only on the patients they think might have the ability to pay the bill outright?

I can't see any logic in hospitals using this for most Medicare patients in a similar situation. While this guy had some private insurance and likely was financially able to pay, most Medicare patients don't have the ability to do so. The end result in most situations is the hospital would end up with even less $ than what Medicare will pay, so it would be a losing proposition.
If hospitalized, Medicare pays for drugs and, if needed, rehabilitation / nursing home. Under observation status Medicare pays neither.
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Old 12-20-2019, 04:34 PM   #12
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Originally Posted by REWahoo View Post
Could this "observation" strategy be something hospitals might try only on the patients they think might have the ability to pay the bill outright?

I can't see any logic in hospitals using this for most Medicare patients in a similar situation. While this guy had some private insurance and likely was financially able to pay, most Medicare patients don't have the ability to do so. The end result in most situations is the hospital would end up with even less $ than what Medicare will pay, so it would be a losing proposition.
From the above article

Quote:

In recent years, an increasing percentage of patients are being placed in observations status. Indeed, some hospitals place up to 70% of their patients in this category.

Why would a hospital categorize a patient under observation status? There are two advantages. First, observation status allows the hospital to avoid accusations of improper hospital admissions or billing by Medicare. Second, a hospital can charge a patient who has only Part A coverage and is on observation status more than Medicare will allow if the patient is admitted.
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Old 12-20-2019, 04:34 PM   #13
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Yes this is a 'loophole'. One of many that Dr. Elisabeth Rosenthal enumerates in her book 'An American Sickness'. Her advice is to always ask what one's status is in the respect and demand to be 'admitted' if possible.
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Hospital bill for 25k not covered by Medicare
Old 12-20-2019, 04:39 PM   #14
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Hospital bill for 25k not covered by Medicare

When I had my knee replacement the doctor had to document all the other things we tried before resorting to the surgery. Theses included synvisc and cortisone shots, exercises to strengthen the knee, and possible lesser surgeries. Only then did Medicare approve the surgery. 40 years of bone on bone wear and tear were not old enough on their own.
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Old 12-20-2019, 04:46 PM   #15
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...a hospital can charge a patient who has only Part A coverage and is on observation status more than Medicare will allow if the patient is admitted.
That's great for those with the means to pay that larger charge, but how many Medicare patients actually have the $ to do so? Seems like a very large percentage of those bills would end up unpaid.
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Old 12-20-2019, 04:47 PM   #16
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Observation is an outpatient status. Outpatient services, including observation, are covered under Part B. The author only has Part A (inpatient facility fees) and what he is calling a "supplement" but is a large group plan through current employment (professor at a university) that is primary to Medicare. He says the primary paid all but 20% of the plan allowable.

The author followed the recommended policy for those working past age 65 with large group plans to only take Part A if they are not contributing to an HSA and wait until retirement to enroll in Part B. This is because Part B pays very little as secondary and beneficiaries usually end up paying more in Part B premiums than they receive in secondary payments. Delaying Part B also delays the 6-month Medigap OEP which allows a person to select any Medigap without underwriting.

The author was provided with a MOON notice, required for observation stays over 24 hours. The notice is required even if the person only has Part A.

Quote:
Medicare Outpatient Observation Notice (MOON)

Enacted August 6, 2015, the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) requires hospitals and Critical Access Hospitals (CAH) to provide notification to individuals receiving observation services as outpatients for more than 24 hours explaining the status of the individual as an outpatient, not an inpatient, and the implications of such status.

Source: https://www.cms.gov/newsroom/fact-sh...on-notice-moon

The MOON must be delivered to beneficiaries in Original Medicare (fee-for-service) and Medicare Advantage enrollees who receive observation services as outpatients for more than 24 hours.

This also includes beneficiaries in the following circumstances:
•Beneficiaries who do not have Part B coverage (as noted on the MOON, observation stays are covered under Medicare Part B).

Source: https://www.cms.gov/Medicare/Medicar...structions.pdf
The concerns about observation and original Medicare revolve around patients being transferred to a SNF. The SNF stay would not have been covered because it requires a prior 3-day inpatient hospital stay.
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Old 12-20-2019, 04:51 PM   #17
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Interesting stuff!
Now, just more things to look forward as I get to Medicare time. So, how do we defend against this happening to us? Will asking to be admitted, be one of the defenses?
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Old 12-20-2019, 06:30 PM   #18
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I feel like you have to be a lawyer to navigate Medicare. This is why I like HSA: I pay up to the deductible, and then it’s all insurance company responsibility.
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Old 12-20-2019, 06:49 PM   #19
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Observation is an outpatient status. Outpatient services, including observation, are covered under Part B. The author only has Part A (inpatient facility fees) and what he is calling a "supplement" but is a large group plan through current employment (professor at a university) that is primary to Medicare. He says the primary paid all but 20% of the plan allowable.

The author followed the recommended policy for those working past age 65 with large group plans to only take Part A if they are not contributing to an HSA and wait until retirement to enroll in Part B. This is because Part B pays very little as secondary and beneficiaries usually end up paying more in Part B premiums than they receive in secondary payments. Delaying Part B also delays the 6-month Medigap OEP which allows a person to select any Medigap without underwriting.

The author fails to mention he was provided with a MOON notice, required for observation stays over 24 hours. The notice is required even if the person only has Part A.

The concerns about observation and original Medicare revolve around patients being transferred to a SNF. The SNF stay would not have been covered because it requires a prior 3-day inpatient hospital stay.
Bolded by me
Yeah that is what we were told that if ever my DF needs SNF care ( he is receiving home care currently), that he needs to be checked into a hospital first for 3 days in order to have Medicare pay for the first 100 days.
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Old 12-20-2019, 08:10 PM   #20
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Originally Posted by MBSC View Post
Observation is an outpatient status. Outpatient services, including observation, are covered under Part B. The author only has Part A (inpatient facility fees) and what he is calling a "supplement" but is a large group plan through current employment (professor at a university) that is primary to Medicare. He says the primary paid all but 20% of the plan allowable.

The author followed the recommended policy for those working past age 65 with large group plans to only take Part A if they are not contributing to an HSA and wait until retirement to enroll in Part B. This is because Part B pays very little as secondary and beneficiaries usually end up paying more in Part B premiums than they receive in secondary payments. Delaying Part B also delays the 6-month Medigap OEP which allows a person to select any Medigap without underwriting.

The author was provided with a MOON notice, required for observation stays over 24 hours. The notice is required even if the person only has Part A.

The concerns about observation and original Medicare revolve around patients being transferred to a SNF. The SNF stay would not have been covered because it requires a prior 3-day inpatient hospital stay.
So, the bottom line, as I understand it is: If the patient had Part B coverage they would be covered?

And the patient, who was a doctor, declined part B coverage to save a few bucks.

Can anyone say Karma?
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