Hospital bill for 25k not covered by Medicare

[RobbieB]

Yes, absolutely, it's the medicare revolving door. Pick up your dad, he's been released. Gotta save the dough.

Yeah I know Kaiser is the devil, killed thousands of people, I read it all the time on the interwebs.

 

[Boose]

Mom had a modified radical mastectomy, plastic surgery and complete axillary lymph node dissection for breast cancer at Brigham & Women's Hospital - a 5-hour surgery with two drains for recovery. After she was brought up to the hospital room and was coherent, an administrator with a clipboard came in to remind us that her impending overnight stay was considered "observation," not being "admitted," and would not be covered by Medicare.

Luckily, Mom has a supplement plan which covered the stay and all the ridiculous doodads like single-use pill splitters that came along with being in the hospital. I guess if she didn't have the Medicare supplement or the $$, I would have poured her into the car and driven her home during rush hour...?

This has been a real eye-opener for me, her 40-something daughter. I hope things get better before I'm her age.

 

[RobbieB]

They're gonna get worse. Consider the national debt.

 

[daylatedollarshort]

Yes, absolutely, it's the medicare revolving door. Pick up your dad, he's been released. Gotta save the dough.

Yeah I know Kaiser is the devil, killed thousands of people, I read it all the time on the interwebs.

To be fair to Kaiser, my FIL episode was at a non-Kaiser hospital. But Kaiser in my area has its own issues. Like 50 people in the ER waiting room and a 6+ hour wait vs. 0 to 5 people at the non Kaiser hospital and a 0 to 1 hour wait at most. I'm frugal but not when it comes to health care and potentially life and death matters.

 

[pb4uski]

Observation status is a crock foisted on hospitals by Medicare's rules and now embraced by hospitals because they've found it a way to get more payments than they'd get for in-patient status. If it walks like a duck and talks like a duck...let's just call it a duck.

MIL was hospitalized for four days and the hospital called the first two days observation...so Medicare would not have paid the subsequent 3 weeks she spent in the nursing home afterwards. Luckily, we were able to stop the discharge because she was not stable. That resulted in two more days of "real" hospitalization and then a covered nursing home stay. (We contacted the state Medicare Quality Improvement Office and followed the protocol for disputing a discharge. That automatically stops the discharge until the review happens.)

I have nothing good to say about hospitals and their remarkable ability to give feeble, vision-impaired and drugged up elderly folks notices and waivers to sign.

+1 It is a "game" that the hospitals willingly play.... what is needed is someone with means to sue the hospital for fraud in classifying their stay... surely a judge could be convinced that the hospital is miscoding the stay to maximize their revenue rather than coding it what it is. A few court victories by patients and this silliness would cease.

 

[EastWest Gal]

Observation status did not exist when I started I’m my career. When it started, it was “23-hr observation”. Now observation status is applied until past the second midnight. Which is weird, because what if you’re admitted at 11:30 PM or 12:02 AM.

It all started in order to shift more costs to the patient. Insurance pays less. You pay more. And the hospital charges you more than the insurance company.

Another example of price gouging in my once respectable profession.

 

[bmcgonig]

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.

Thanks for that explanation.

Here's also a good site that explains it all and is actually trying to change it thru a lawsuit. See especially the links to Articles and Updates at bottom of page. So even if you have part B and Medigap which should cover your stay whether inpatient or outpatient (observation) you're still going to pay for the Skilled Nursing Facility that Part A would normally pay for if you're outpatient rather than inpatient.

https://www.medicareadvocacy.org/medicare-info/observation-status/

 

[bmcgonig]

I'm still confused how a professor of Radiology, ie the author of the article, could be surprised by all this given the fact that the surgery was elective and he had all the time necessary to determine costs.

Edit: maybe it wasn't elective and he found out he had Prostate Cancer in the ER. Can't imagine that scenario either. Even if true he would have plenty of time to plan the surgery.

 

[REWahoo]

They're gonna get worse. Consider the national debt.

I'm surprised you'd make such a comment since the national debt is the ultimate "blow that dough" experience.

 

[HadEnuff]

Thanks for that explanation.

Here's also a good site that explains it all and is actually trying to change it thru a lawsuit. See especially the links to Articles and Updates at bottom of page. So even if you have part B and Medigap which should cover your stay whether inpatient or outpatient (observation) you're still going to pay for the Skilled Nursing Facility that Part A would normally pay for if you're outpatient rather than inpatient.

https://www.medicareadvocacy.org/medicare-info/observation-status/

Thanks for the link...anyone with Medicare, or anyone helping a loved one wade through the maze of receiving hospital care with Medicare, should read the information. One really cute trick used by the hospitals is to "admit" a patient, and then later, without the patient's knowledge, retroactively reclassify the stay as "observation care"...uh...really This is why the world needs lawyers...

 

[donheff]

Hospitals all use various tactics to avoid classifying a visit as an admission. I had shoulder surgery a few years ago and was in the hospital for 36 hours - still no admission and no Medicare Part A. I assume Part B would have covered 80% but I don't have Part B. My Federal policy covered the charges the same way it would have when I was working (i.e. sane deductibles and co-pays).

 

[Bamaman]

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.

When my wife had a knee replacement last year, her doctor's group had a whole floor of the hospital to themselves. In the 3 days she was admitted, they had 12 knee replacement patients in "physical therapy" twice a day @ $550 each class. They were grossing $13,200 per day for very little therapy. The hospital bill was $92K, not including the surgeon's bill. Multiply that by a whole year, and this one doctor's group is responsible for an incredible amount of sales for the hospital.

We'll keep that article in our minds, especially if any additional physical therapy is going to be required. Thanks,

 

[JoeWras]

And we wonder why there are generational wars. The kids see this and have to shake their head, watching a system crumble before they'll need to engage it seriously.

I feel that way a bit too, as a Gen Jones. Early in life, I saw a system that worked pretty good. My mom and dad had very few issues despite their many visits and hospitalizations. It was only after 2010 where I saw dad being "gamed" by the system a bit. But only a bit.

Later (2016) I had my surgery. Most went fine, but I was swept up by a surprise out-of-network charge from (ironically) the "admitting doctor." Some guy I saw for 2 minutes asking me if I felt OK.

Everything's a trap now. You have to hire advocates and lawyers before you walk into the hospital. Looks like it will only get worse.

 

[Tadpole]

I went in for an angiogram/stent placement inside the local hospital with a possible one day stay. When I went in I told the man interviewing me (admitting?) that I wanted to emphasize that Medicare was my primary insurance and set the price for my secondary insurance (Federal GEHA). GEHA pays the my 20% of the Medicare payment. I also told him that I wanted all personnel involved in my case to accept assignment with no non-Medicare contractors involved. (The hospital has a habit of simply telling people "of course we take Medicare" and seem to look at you funny when you use the word "assignment" as though they never heard it before.) In this case the man said he didn't know what "accepting assignment" meant so he disappeared in the back for a couple of minutes. When he came back he assured me that all procedures would be under assignment.

They took me back for my 10AM procedure. I had quit drinking anything hours before. Then they proceeded to delay my procedure until about 3:30PM or 4PM as I lay there with nothing to eat or drink being ignored as though forgotten. They said they were busy with emergencies. I ended up staying overnight and, so far, everything has been covered by Medicare. I have wondered if my gentle reminder about Medicare assignment lost me my place in the queue.

So, when I went for an after surgery check with the doctor who works for the same organization that owns the hospital, the desk wanted me to sign an agreement they had recently drafted for all patients to sign. It essentially said that they could charge anything and I agreed to pay what my insurance didn't. Calling the agreement a blank check, I pointed out to them that it was not even legal for them to make a Medicare patient sign such an agreement if they accepted assignment which they do. Then they huddled and ended up telling me that they wanted me to sign it but it wasn't actually required. So far it looks like I now don't see doctors but see PAs and NPs. Again I don't know if that is the consequence of refusing to issue them a blank check.

The organization, PeaceHealth, runs most of the medical facilities near me and keeps expanding it's monopoly over key specialty areas around here. I keep having to remind/correct their staff and doctors who assume the Federal Plan means they can charge more than their Medicare assignment agreement. I have told my husband to quit giving them the card for the secondary insurance since Medicare sends the bills directly to them when finished so the doctors don't need to have it.

What if I get old(er) and frail(er) and can't advocate for my pocketbook? What if I have a stroke and get observed then sent to a nursing home without coverage? I have asked myself these questions and never figured out an answer. I wonder who lobbied for two admittance statuses under Medicare?

My husband was referred to speech rehab but he didn't want to go. They called him and he told them no. Later they called back still pressuring him and, during that second conversation, he discovered that Medicare had already disapproved the therapy. He told them not to call again about undisclosed disapproved services.

 

[MrsHaloFIRE]

As far as observation, I think its crap and theyre wringing money out of sick people because they can. I also have the impression that it lets them bypass some medicare penalties for readmittance (medicare says if you are a revolving door we will penalize what you get reimbursed). SO its not considered a readmittance it the patient wasn't admitted to start with. ALso, if you haven't hit 3 days inpatient bc of a buncha BS, appeal appeal appeal. THat in an of itself might buy you enough inpatient time to get covered SNF or rehab. The hospital it REQUIRED to give you info on how to appeal, and you can drag feet and appeal latish in the appeal period, and then let the hospital know you just complied with all the appeal requirements and theyre not discharging anyone til you hear back from the appeal. What is also on my mind are accounts of folks doing their due diligence, saying delivering a baby. They've selected an in network hospital and an in network provider. And then unbeknowance to them the anesthesiologist that appears is out of network. They bring in a second surgeon that's brotherinlaw of the first surgeon who surprise surprise, is also not in network. So you've done all your groundwork and then you get slammed by a bunch of outofnetwork fees you knew nothing about at an innetwork hospital.

 

[JoeWras]

the desk wanted me to sign an agreement they had recently drafted for all patients to sign. It essentially said that they could charge anything and I agreed to pay what my insurance didn't. Calling the agreement a blank check, I pointed out to them that it was not even legal for them to make a Medicare patient sign such an agreement if they accepted assignment which they do. Then they huddled and ended up telling me that they wanted me to sign it but it wasn't actually required. So far it looks like I now don't see doctors but see PAs and NPs. Again I don't know if that is the consequence of refusing to issue them a blank check.

Probably has nothing to do with your failure to sign.

But your blank check mention is my concern. It is getting to the point you need a lawyer with you on admitting. Just crazy.

Most people won't close a real estate deal without a lawyer. Yet here we are, signing our life away to potentially 100s of thousands of dollars of liability when we enter a hospital.

 

[fh2000]

Another reason I'm going medicare advantage.

Wife came home with good story today. Took Pops for post op visit. Pops was in rehab. Pops needed to be transported to doc's office (after surgery for broken hip) doc says you need xray, go across the street. Across street says we don't take that insurance anymore, go back to hospital where surgery was done. Hospital says we don't take that insurance anymore go down the road 20 miles.

Meanwhile back in the car the 87 year old guy waits in pain...

Xray postponed until next visit. That stuff doesn't happen at Kaiser.

From what I read, the only good Medicare Advantage plan is with Kaiser, no?

 

[youbet]

From what I read, the only good Medicare Advantage plan is with Kaiser, no?

No, that's definitely not true. Where did you read that?

 

[Spock]

Threads like this are really depressing. You save and scrimp just enough to not eat cat food when Megacorp gives ya the boot only to get robbed by paying 20K/year in premiums + deductibles/co-pays
and then pirate medical professionals/hospitals run a cannonball up your financial arse.

I guess this is where the advice of "set the bill up on a $30 monthly payment plan for the rest of your life" comes into play. I was surprised at the number of neighbors at a recent get together had adopted this practice but it starts to seem fairer with each thread like this.

 

[MissMolly]

From what I read, the only good Medicare Advantage plan is with Kaiser, no?

Not at all true. My Medicare Advantage plan is not Kaiser and I think it is very good.

 

[VanWinkle]

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?

Karma!!

 

[travelover]

From what I read, the only good Medicare Advantage plan is with Kaiser, no?

No, that's definitely not true. Where did you read that?

In the Kaiser brochure.

 

[ncbill]

As one of our posters here said on another thread:

"I'd start thinking about talking to a lawyer.

I bet they will pay when they get a lawyer type letter."

 

[John Galt III]

That form they want you to sign saying you agree to pay whatever they want, above and beyond what insurance pays, has been around for many years. I used to not sign it, and tell them it is illegal, and got seen anyway. Now I just sign it, but write next to my sig something about copay and coinsurance only. If they have the electronic form you can't write on, sometimes I sign, sometimes not. They've never actually hit me up for charges above and beyond my copay or coinsurance anyway, so far. But.. my mom once got 'balance billed' for charges above what her medicare paid, several hundred dollars worth of balance billing, and I called the provider up and told them that was illegal, and that she would NOT be paying that bill, and don't send another one! And they stopped sending her that bill. If I weren't advocating for my mom, she would have just paid it.

 

[daylatedollarshort]

The ER department at a local hospital didn't fit one of our kids in at all one night, so we left in the early hours of the next morning to call our regular doctor, who would be at work in a few hours. The ER staff tried to get me to sign a form to say I was refusing treatment before we left, which was pretty much the opposite of what had happened. They were pretty aggressive about it. I found out the next day after complaining to the customer relations department their procedures were that the ER staff was supposed to have referred us to the ER department a less busy nearby hospital and we would still be covered, if they were too full to fit us in. So they pretty much did they opposite of what they were supposed to do by not giving us treatment, not referring us elsewhere, and trying to get me to sign a document saying I refused treatment, which isn't what happened at all.