91 yr. old mom back in hospital but they coded it 'observation' rather than 'admission'. Question about re-admit...

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.

I have no idea. Get the patent advocate on the phone. What is their care plan for her?

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.

So, Marigold, how did this going?

This just happened to us. Mom went into ER and they kept her but she was also considered ‘observation’. I believe after three days Medicare pays. Mom stayed a little longer than three days running tests and so forth. They also have to do a mental evaluation before going to nursing home. They did with my mom. They said it’s standard procedure before entering a nursing home. We are in Louisiana. Not sure how this is anywhere else.

They kept mom, actually started on physical therapy while in the hospital. Then released to a nursing home for skilled nursing rehab. Skilled nursing rehab is wonderful in helping to regain strength back. Do take advantage of skilled nursing rehab. The hospital actually asked me to register mom at the nursing home the day before arrival.

The nursing home sent transportation to pick mom up from the hospital. Then she was sent home in three weeks with home health care. Home health is covered by Medicare as well. It consists of OT, PT, nurse and aide. Take advantage of home health if offered. Every bit of therapy helps.

Be aware that Medicare only pays for a certain amount of days in the nursing home for rehab. Mom went a couple of days over so I am assuming we will pay for that out of pocket.

Mom has a supplemental insurance too, Humana gold plus.

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.

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

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.

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.

You must talk to her hospital social worker immediately. Your mother needs to be admitted to the hospital for three days. If your mother might qualify for some sort of assistance, get thee to the business office at the hospital where they can help you help mom apply for Medicaid. I did this for my dad. In my state he quickly qualified for something called Extra Help while the Medicaid application was pending. "Extra-help" allowed him to be admitted to a long-term care hospital for two weeks while he received treatment so that he could save his last two weeks of rehab coverage from Medicare. Medicare only covers so many days before you have to reset the coverage with 60 well days. Understand that those days of coverage are available but not guaranteed and once a patient has spent 20 days in rehab, coverage drops from 100% to 80%. Some supplemental insurance will cover the 20% difference but not all. Make sure that her's does. Your mom will need to go to a less "aggressive" rehab facility, preferably one that has a good long-term care facility attached to it. Do your homework to determine her best choices. There, she will receive care, some occupational therapy, and physical therapy until Medicare wants to discharge her, but it will buy you some time to determine your next step. If she can't go home, she can switch to self-pay (not discharge) while you apply for long-term care medicaid if that is what she requires. At this point, you are working with the social worker and business office at the rehab/nursing home. I am not a doctor, but it might be possible for her to heal, but obviously, at her advanced age it will take a longer than it would for you or me. Time will tell. My point being that you might have to do all of this, but she may improve enough to go home....just not on the ridiculous fast track that Medicare dictates. It's a lot to learn for you but the people in the business offices see this quite a lot and many of them are very kind people. Also, if you haven't already, it would be good to see an elder law attorney.

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.

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.

Almost positive that under observation is not covered and very expensive. Talk to hospital billing and find out asap.

Call Medicare and ask them.  They will tell you.  Get the social worker in play.  She will help you.  Medicare does pay for rehab, but it would be to an SNF unit for PT and strengthening.  Again, call Medicare.  They have a 24 hour line.

Don't let them discharge her. If she is not healthy enough for 3 hours of PT a day, she is not ready to be discharged and every hospital must post notice of your right to dispute a discharge that is inappropriate.
Get Ombudsman and perhaps SW from Agency on Aging to advocate for full admission for proper care and pain management. Her medication/pain management, transfer needs, etc. need more than LTC facility can provide at this point.
About not being up to 3 hours of PT at skilled rehab. They may schedule 3 appointments a day, but start with simple range of motion, arm strength, and basic functioning like how to manuver into lift assist devices. Some is OT, not PT. Actually this should szart during her full hospital admission. Also PZ should come to her room as she is not healed enough for transport to PT room yet.

Let them know you will file a formal complaint with Medicare and Joint Commission on Hospital Accreditation if they give you push back.

They will try to get you/you LO to sign off on tranfer/discharge under fear of getting full bill for extra days. This is common practice, ignore it. There is a reason posting patient rights is the law. They were also supposed to give patient booklet and explain all her rights the day of her admission...but many wait. Same for Skilled Care Facility.

After she is safe and healing, I would still report the doctor and hospital to Medicare & Joint Commission, so they have record that this is happening. Then next time, next patient, they know it's happened before.

They are probably worried that complications will occur due to her age. If this happens while she is in the hospital, they Must continue to provide care until she is truly well enough to go to LTC. They want her out before thst happens.

Does your mother have Medicare Supplemental? And if so, what plan letter do she have?

I had the experience where hospital delayed giving the notice until Friday evening, when visiting hubs in hospital, post-surgery, gastric bleed one week after lung lobe removal for lung cancer. They know when given after business hours, and late Friday, you can’t do anything about the discharge until Monday. I also was not well enough to care for him, but he signed off on the paperwork they shoved under his easily sedated nose, forcing me into caring for him at home way too soon. Both surgeries, they pulled that little trick.

A dear friend had a heart attack earlier this year. She was taken straight to OR when she arrived in ER. Stinking hospital kept her, but coded her heart attack admission through the ER as observation for a heart attack, and immediate heart surgery. Appalling!

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).

Thanks, cjwilson

This info helps!

Initial treatment would be an X-ray in any ER, not a trip straight to the CT machine. They triaged her and then determined further diagnostics were done BASED on the result of the X-ray. Hospitals have to follow protocol in an ER. They may not get reimbursed if they didn’t X-ray her first.

Regarding pelvic fractures, they are reported by many of the patients I took care of to be extremely painful.

Not only are they reported to be painful but there is really no treatment except pain mgmt and rest. I don’t even think they would order PT while hospitalized. A pelvic fracture will limit movement due to pain.

I took care of many seniors with a fractured pelvis as a homecare nurse. There was nothing I could do for them except teach them pain control and maybe upper body strength exercises but not much else until the fracture heals. There is no rationale for sending them to rehab as usually these folks were independent prior to the fracture. In elderly folk bones can fracture spontaneously from osteoporosis. The pain is real.

Folks were rarely sent to rehab with a fractured pelvis because they can’t do PT or OT due to pain. Thus sent home with pain medications and order to rest.

Please bear in mind that now you will need to be vigilant with skin care and inspection for pressure ulcer formation due to being in one spot for too long. You may want to think Palliative care if your Mother doesn’t improve.

Lastly the best place to be is out of the hospital for an elderly person with a non fatal illness. An elderly person already has a weakened immune system and the chances of catching MRSA, c.diff & VRE, not to mention staph infections. Pelvic fractures are generally not fatal.

Very sneaky, that “observation” status. Truth told, one has to be pretty ill for hospital admission these days even for non Medicare patients.

Isn't a Cracked Pelvis the same as a broken pelvis? at this age? Osteoporosis seems like the primary clue that something else might have been amiss.

I have never head of 3 hours PT. PT must be coming in several times a day. They are also looking at her age.. 91 with osteoporosis. Can you ask for 2 hours of PT done in spurts during the day? My friends mom has PT 3 times a day, for about 20 minutes at a time. It's usually not that long from what I have seen with my elders.

Does your family have a living trust? No need to answer here, just food for thought. DNR, POLST....
Maybe they are going to observe her to see if she gets infections? I am not sure, but it sounds very painful.
If they try to push her out to go home, ask for palliative care or Hospice evaluation. They can evaluate her for these services so you can get help at home, so they come to you instead of trekking mom to doctor appointments.

8/25 update Thank you all so much for your very informative answers! Mom was discharged to a SNF/rehab facility. The caseworker at the hospital found a waiver that was put into effect January, 2017 titled ‘eligible Medicare patients can receive skilled nursing and rehabilitation care without a three day prior hospital stay at eligible SNFs.’ Her doctor is part of the quality independent physicians that have participated in this program so our thinking is we should be good with the admission vs observation dilemma. As I’ve said before, this is a learning experience, We are even learning that we don’t know what questions to ask. I hate that the system seems so broken. I’m very thankful for family members who are seeking answers. My heart goes out to patients that might not have family to advocate for them.
So right now she is in a facility that is making sure that she moves during the day. Not necessarily “PT“ but movement. From what we are understanding, there is no PT that will help a broken pelvis along, that the main objective is to keep her resting and comfortable but also moving so that pneumonia and/or blood clots don’t form.
Her tentative discharge date is Sept 4. She wants to be home, yet she is scared that she will have another melt down because of being so overwhelmed like she did when she was home before. She has come such a long way though, I don’t think that will be a problem. Dad would like to see her stay there as long as she can and we agree.
At this point, she is coping with such grace. She is still as clear as can be mentally, it is the physically that is what she’s dealing with. Again, thank you all for the answers. This forum has been a great resource for me and my family. I’m thankful for the shared experiences and encouragement and knowledge.

Observation saves the Medicare a lot of money. Medicare will still cover the hospital bill however if your Mom needs a nursing home Medicare will deny it and she'll have to be self pay.

My 90 yr old mom had a similiar situation. The 3 hrs of daily rehab is required, but it's not as bad as it sounds. The exercises are totally necessary and they will only make them a difficult as mom can handle. I strongly recommend it. it will be broken up into different sessions during the day.

Update 8/31. Mom is home, was discharged from SNF this morning. She was anxious about coming home because of the meltdown (anxiety attack) she had several weeks ago. We tried to make the guest room - her new room - very comfortable. Bringing her handmade quilt from her bed to her new bed. She’s had a great day and has progressed so much!
Home PT and OT and a nurse are already scheduled. Plus a home health attendant to come stay for a few hours several times a week to give dad a break.
Again, thank you for the answers and encouragement! Time and hard work on her part has done wonders.