Skilled Care Services of Medicare

Over a million Americans each year are denied access to Extended Care (skilled care) services of Medicare, if they were not classified as "admitted" when they go to the hospital. We are well aware of the problem, but clients seldom are. CMS has come down hard on hospitals for "upcoding" to admitted status to receive a higher payment for their services, than they would if they were coded as observational status.

Sometimes we overlook important matters like this, but one gentlemen , Lance of a Midwest state, has experienced this situation. Lance got a call from the daughter of one of his Med Supp policyholders describing exactly what is being discussed. Lance took the time to carefully interview his client's daughter, and forwarded the conversation to me. Lance gave permission that this information could be shared and we are doing so because I think his work is so well done, and so complete, that you will be able to utilize it should such a situation develop for you.

Extended Care Example

Here is Lance's discussion with his client:

Bev: During July of 2011 my mom fell and broke her hip and had it replaced. Then in January 2012 she fell and broke her left femur in three places and had it pinned. Then in October of 2012 she fell and broke her pelvis in two places. It was cracked in half. She was in the hospital for five days and received pain meds and intravenous hydration. We were told that she should go to a convalescent facility that would help take care of her. She couldn't even roll over in bed because of the pain.

We put her in a convalescent home (Extended Care) in a Midwest state and the first thing we were told when we arrived there was that Medicare would not cover anything because she had not been admitted to the hospital. She was there under observation only.

Lance: During that time did they give her any treatment?

Bev: Yes. I mentioned the pain meds and hydration. That was it.

Lance: She was treated but never admitted?

Bev: Yes, she spent five days there. It wasn’t like it was overnight.

Lance: So who ended paying for her stay at the convalescent home?

Bev: She did. It was $6,900 for 30 days! They also told us that we had to pay in advance.

Lance: That was well over $200 per day. Did she have a recovery?

Bev: We brought her home and took care of her. With a broken pelvis she needed lots of bed rest. It took her another two months to walk with a walker. She still is unsteady on her feet. There is now a family member with her 24 hours per day.

Lance: That’s where you are right now?

Bev: Right!

Lance: The lesson learned is understanding the difference between a hospital admittance and a hospital observation.

Bev: I asked the hospital after the fact that since she was in pain, couldn’t they admit her. They said that it would it be the falsifying of documents do so. I said, “For God’s sake, she was there for five days.”

Lance: What did they say after that?

Bev: They said “No.” They said that they could not change the way they originally admitted her.

Lance: Then there is no way of knowing that this would happen?

Bev: We thought that she was admitted to the hospital. We were never told that she was an observation patient until we were ready to leave.

Lance: Were you surprised when you found out?

Bev: We were stunned. They told us that she should go to a rehab facility. We thought that Medicare would cover mom’s stay. They wanted their money up front…a full month.

Lance: How did they know how long she would be there?

Bev: It went month by month.

Lance: I suppose they have had situations where they didn’t get paid.

Bev: I’m sure that is the case.

Lance: After 30 days your mom was able to come home.

Bev: Yes, she was in a wheel chair for two months.

Lance: So where does that leave you with the whole experience?

Bev: I was disappointed in the way it was handled. We would have liked to have known that she was an observation patient right off the bat.

Lance: So what can be learned from this is that the family must ask the hospital from the get-go if the stay in an admitted stay or an observation stay. By doing this the family can be fully informed right from the start.

Bev: Right

Lance: Anything else that you can share with others about the experience?

Bev: Not really. I want people to know their admission status once someone is in the hospital. If they tell you that it is observation only, you should do everything possible to change it.

Lance: We will likely see more of this. This saved the Medicare almost 7K.

Bev: I’m sure that’s the case.

Lance: Any other thoughts?

Bev: No. We covered it. If Mom hadn’t had the three girls, she probably would have been in the rehab facility longer if she didn’t have family to help take care of her. Each one of us takes a 24 hour shift.

Lance: Thank you.

Now, stop for a moment and think about this. The lady had a broken pelvis, and spent five days in the hospital. I would think that would be reason enough to be admitted. Then the hospital told the lady's daughter to take her to "a convalescent facility that would help take care of her." No mention that the hospital hadn't admitted her. Nor any mention that Medicare would not pay the expense of the convalescence. Let us know your opinions!

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