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Our 91 yr. old mom is back in hospital but they coded it observation rather than admission. From what I understand, if she's 'under observation' it's not covered by Medicare? She had fallen and ER originally just did an X-ray that showed a cracked pelvis bone. Upon a return visit to the ER by ambulance because of excruciating pain, they did a CT scan which showed not 1 crack but 4 fractures on the pelvic bone!


Many questions here, first off, why didn't they do a CT scan originally on a 91 yr old woman with osteoporosis? She can't be discharged to re-hab because she can't handle 3 hrs of PT per day so the next step is a care facility but because she was coded as 'observation' for 4 nights it would be self pay? From what we understand, she would have had to be 'admitted' in the hospital for at least 3 days before they would discharge her to a care facility and be covered by Medicare.


2nd question - what's the difference between being 'admitted' and being 'under observation'


Who should I contact about these questions of why just the x-ray and why she wasn't re-admitted but only under observation? What is the difference between 'admission' and 'observation'?


We are new to this. very thankful that both mom and dad are pretty healthy for 91 and this is the first real issue.


Thanks in advance and please ask for clarification as I'm not sure this has made sense.

Before or after admission at 72 hours it will be recoded as an admission. If she is there 72 hours, the discharge planner will admit her to a facility. If they try to discharge her to home you can tell them it is an unsafe discharge and you can’tbtake Her home.
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I am a Geriatric Care Manger who specializes in long-term care and dementia. Here is something I wrote up for my families on Observation vs. Inpatient. I hope this helps.

Know Your Rights
Observation vs Inpatient
When the doctor tells you that they are going to admit your loved one to the hospital you need to ask “are they being admitted as an inpatient or observation?”
If the answer is inpatient there is nothing else you need to do. If your loved one is being admitted under “Observation” you need to be aware of some potential problems.
Observation Status is paid by Medicare Part B, while inpatient status is paid by Medicare Part A. Individuals who are enrolled in Medicare Part A, but not Part B will be responsible for paying the entire hospital bill if they are listed as “Observation” status.
When an individual’s status is “Observation” they may be charged for services that Medicare would normally pay for such a co payment for each outpatient service they receive, 20% of the Medicare-approved amount for most doctor services after the Part B deductible.

In order to get Medicare to pay for rehab in a long-term care facility the individual must be listed as an inpatient for three (3) midnight's. If your loved one’s status is “Observation” Medicare will NOT pay for their rehab; it will be an out of pocket expense.

Since March 2017, federal law has required hospitals to provide both oral and written notification to patients who are listed as outpatients or Observation Status for more than 24 hours that they are being admitted under Observation and are not being admitted as an inpatient. This is called the “Medicare Outpatient Observation Notice” or (MOON) and it must be given within 36 hours of admission to the hospital. 

What Options do you have if I your loved one is admitted under “Observation?”
1.    If the individual is still in the hospital:
a.    Ask the doctor’s to help change their status to inpatient, only the doctor can change an individual’s status.
b.   Use Medicare’s “two-midnight rule.” (Not to be confused with the (3) three midnight rule above.)This states that if their doctor expects the individual to require hospital care for at least two mid nights, the hospital should be able to admit the individual as inpatient.
c.    Consider other resources for care such as: an inpatient rehabilitation hospital, home health care or, outpatient therapy. These do not require a three (3) day inpatient stay.

If the individual is no longer in the hospital: Medicare does not have an official method to appeal the Observation status at this time.

Question?? Does your mom have Traditional Medicare or an Medicare Advantage Plan? Many of the Medicare Advantage Plans do not require the three mid-nights to qualify for skilled care (therapy) in the long-term care (nursing homes).
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Tiger55 Aug 23, 2019
What 👍 info, thanks cjwilson! It's so confusing, especially for old people..Yikes.
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I think what might be going on is this: Your mom was admitted to the hospital originally, right? So, if she is readmitted within 30 days for the same issue, Medicare makes the hospital eat the charges.

Call the patient advocate and call them on their BS. Get her admitted.
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marigold56 Aug 19, 2019
Thank you BarbBrooklyn. This makes sense. Is there a time limit on correcting this? She may be discharged today.
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The problem with them not admitting her is that then Medicare will not pay for rehab in a nursing home afterwards. She must be admitted to a hospital for 3 days before medicare will pay for the rehab. Next time insist she be admitted.
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Tiger55 Aug 23, 2019
You can't just 'insist' on admission, (it's by medical facts & not what family thinks). Hosp admin has criteria in place for a reason, (sometimes lots of grey area), but it's a necessary system for hosp to run. You can ask the patient advocate to review the facts before LO's discharge. Also an appeal process exists. But surely it's understandable that insurances try to limit the chronic cycle of elderly admissions. Or we'd all be getting the biggest tax increase (&premium increases) that you've ever seen.
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This is such a travesty against seniors, and their families. When I have my total hip, plus the two knee replacements once the hip is healed enough, I will be forced to have them under Medicare’s drive through joint replacement policies. They are trying to force seniors home before the anesthesia has fully cleared the body, without the stronger, and necessary pain control only available in hospital post op room. They give paper prescription for pain medication at discharge, and the patient has to go inside the pharmacy personally, and stand in the pharmacy counter line to wait for the prescription to be filled, on the way home from the hospital. Less than 24 hours after the joint replacement. It’s an ugly thing, shoving the cost and medical care post op, onto the elderly, and the families, if even someone in the family can assist. We elderly are being denied rehab post joint replacement, if we cannot pay for it ourselves. Slow genocicide of the elderly.
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Bigsister7 Aug 22, 2019
I was a PT for 40 years and I can tell you that a longer hospital stay does not improve the outcome for people who get joint replacements. There is too much sitting around, even with a rehab program. You are better off getting back to your life.
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Our doctor told a family member who broke her pelvis that this is about the most painful break one can have. A hip fracture is more common and may be more complicated but it's not nearly as painful as a pelvic fracture. So please, talk to her surgeon about insisting that your mother get the care she needs and is entitled to.

The hospital did what was financially best for them, not what was medically best for the patient. It's a question of whether Medicare will pay for the hospitalization; they will be for an admit but not for 'observation.' And after a three-day admission rehab will be paid for up to 100 days. Appeal any decision the hospital makes and let them know you will not accept this lying down.
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wakankasha Aug 22, 2019
I agree. When I was 19 my pelvis was fractured after being struck by a car as a pedestrian. It was a long time ago, but what I remember is being in the hospital for two weeks. They wanted me to move as little as possible. I wasn't allowed out of bed for the first week, so I wasn't putting pressure on the pelvis! Which meant using a bedpan, which was very painful too. After that I used crutches.
I really feel for Marigold's mom. Can't imagine what that is like for someone in their 90s!! Plus PT wasn't recommended, the bone just needs time to heal. It takes 6 weeks for bone to heal according to my doctors.
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Here's what we do:
When in ER they put the papers for you to sign - We refuse saying "We are under emotional stress making sure Mom is ok".  We will talk to the social worker in the morning.  We get the smile of "O you know the system"
When we meet with the ER doctor we INSIST on making sure it is not for observation. We always know she will need rehab, and as someone has already stated, the longer your LO is in the Hospital or in Skilled Nursing the more rehab your LO needs.
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mollymoose Aug 22, 2019
My mom was admitted to the hospital in Jan of this year. The Dr. came to us later & told us that HIS decision to admit had been over-ridden, and she was placed as “observation status”. He was angry & had to spend time arguing to get her officially admitted. I didn’t ask who overrode his decision or who he argued with, but I thanked him profusely. He had never seen my mom before, she had never been his patient. Evidently, some entity is cracking down on actual “admissions” in the elderly.
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Almost positive that under observation is not covered and very expensive. Talk to hospital billing and find out asap.
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NeedHelpWithMom Aug 22, 2019
After three days it is covered. Just went through this with my mom. Before three days will not be covered. Sad.
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The 3 day admission policy may be changing though - read this recent article: https://www.forbes.com/sites/howardgleckman/2019/08/19/are-we-nearing-the-end-of-medicares-three-day-rule-that-makes-patients-pay-for-skilled-nursing-care/#49aee45869f4
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cetude Aug 22, 2019
Changes have not been made yet and it could take years; knowing government the rules will be ten times more confusing than they are now.
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Observation is overnight stay (two days max) and Medicare will pay for that. However, there may be an issue about paying for routine home medications with these kinds of stays. Once converted to "in-patient" that becomes DAY ONE. For more information see:

https://khn.org/news/observation-care-faq/


You have to be in the hospital for 3 days (NOT COUNTING the day of discharge) and Medicare will pay up to 100 days rehab in skilled nursing facility and must show improvement. If they do not improve the SNF will discharge them and recommend nursing home which goes into Medicaid. A fractured hip can be fixed, but not the pelvis. With a fractured pelvis I doubt she will improve due to the pain and there are no medical interventions that can fix that so there is a possibility she may become permanently bed ridden as elder heal much slower.

When it comes to more complex pelvic fractures that in itself is life threatening due to damage to internal organs, but more minor fractures are left up to bedrest and physical therapy, which can take 12 weeks to heal. Pinning internal pelvis is very invasive surgery with much risk, but the surgeon would have to make that call.

Here is more information on pelvic fractures
https://www.cedars-sinai.org/health-library/diseases-and-conditions/p/pelvic-fracture.html

A single fall can be a "game changer" to permanent bedridden, and even impending death. That's why people do fall precautions including using walkers. Most falls occur when first getting up so people even use fall mats to help break the fall.
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NeedHelpWithMom Aug 22, 2019
My mom’s poor roommate in skilled nursing rehab fell and broke her femur. She had been in rehab for two months and not getting any better. One day, they took her to the hospital and we never saw her again. All of her kids and grandkids pictures were left behind like she was returning. They didn’t fill that bed with another patient.

Some breaks are awful. Apparently, the femur bone is a tough one to recover from. At least for her it was. She kept thinking she was going home.

When I had mom’s care meeting with the social worker I mentioned how sweet her roommate was and how she was anxious to get back home the social worker said that she was a long term care patient. Does that mean she wasn’t ever going to be able to go home? I didn’t want to ask the social worker because I am not her family.

What happens if a person can’t recover from a broken bone? The lady was asking the nurses for pain shots.
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