Tag: Medicare appeals

Class-Action Lawsuit Seeks To Let Medicare Patients Appeal Gap in Nursing Home Coverage

August 1, 2019

By Susan Jaffe | Kaiser Health News | August 12, 2019 | This KHN story also ran on and

Medicare paid for Betty Gordon’s knee replacement surgery in March, but the 72-year-old former high school teacher needed a nursing home stay and care at home to recover.

Yet Medicare wouldn’t pay for that. So Gordon is stuck with a $7,000 bill she can’t afford — and, as if that were not bad enough, she can’t appeal.

The reasons Medicare won’t pay have frustrated the Rhode Island woman and many others trapped in the maze of regulations surrounding something called “observation care.”

Patients, like Gordon, receive observation care in the hospital when their doctors think they are too sick to go home but not sick enough to be admitted. They stay overnight or longer, usually in regular hospital rooms, getting some of the same services and treatment (often for the same problems) as an admitted patient….

(Photo courtesy of Betty Gordon)

But observation care is considered an outpatient service under Medicare rules, like a doctor’s appointment or a lab test. Observation patients may have to pay a larger share of the hospital bill than if they were officially admitted to the hospital.Medicare’s nursing home benefit is available only to those admitted to the hospital for three consecutive days. Gordon spent three days in the hospital after her surgery, but because she was getting observation care, that time didn’t count.

There’s another twist: Patients might want to file an appeal, as they can with many other Medicare decisions. But that is not allowed if the dispute involves observation care.

Monday, a trial begins in federal court in Hartford, Conn., where patients who were denied Medicare’s nursing home benefit are hoping to force the government to eliminate that exception. A victory would clear the way for appeals from hundreds of thousands of people. [Continued at Kaiser Health News, Next Avenue or Salon]

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Protecting California’s Seniors From Surprise Hospital, Nursing Home Bills

August 29, 2016

By Susan Jaffe | Kaiser Health News & California Healthline | August 29, 2016

Californians with Medicare coverage would no longer be surprised by huge medical bills stemming from “observation care” in hospitals under legislation that state lawmakers approved overwhelmingly last week and sent to Gov. Jerry Brown to sign into law.

The sticker-shock can happen when people go to the hospital but health care providers are not sure what’s wrong. If the patient is not sick enough to be formally admitted, but still not healthy enough to go home, they can stay in the hospital for “observation care,” which Medicare considers an outpatient service. That can mean higher out-of-pocket expenses for the patient….And because observation patients have not spent the required minimum of three straight days as an admitted patient, Medicare will not cover their follow-up nursing home expenses after discharge. Observation care doesn’t count….“I don’t think the average person knows the difference,” said Sen. Ed Hernandez (D-West Covina). Hernandez introduced the legislation requiring hospitals starting Jan. 1 to tell all patients if they are getting observation care.

…The legislation also would require the nation’s first minimum nurse-to-patient staffing ratios in observation care units for hospitals that have separate units for those patients. “We are still the only state that has these very specific mandated ratios for every unit of the hospital that have to be adhered to every minute of every day,” said Jan Emerson-Shea, a spokeswoman for the California Hospital Association, which represents 400 hospitals. Those staffing rules, however, excluded observation care units.

“We wanted to make sure hospitals didn’t use observation care as a loophole to avoid any of the minimum nursing staffing requirements,” said Sen. Hernandez. [Continued in California Healthline or San Jose Mercury News]…

Medicare’s Efforts To Curb Backlog Of Appeals Not Sufficient, GAO Reports

June 10, 2016

By Susan Jaffe | Kaiser Health News | June 10, 2016

Despite interventions by Medicare officials, the number of appeals from health care providers and patients Growing Wait Time1 challenging denied claims continues to spiral, increasing the backlog of cases and delaying many decisions well beyond the timeframes set by law, according to a government study released Thursday.

The report from the Government Accountability Office, said the backlog “shows no signs of abating.” It called for the Department of Health and Human Services to improve its oversight of the process and to streamline appeals so that prior decisions are taken into account and repetitive claims are handled more efficiently.

HHS officials have acknowledged the problem. Although a judge is required to issue a decision within 90 days, the average time from hearing request to decision is slightly more than two years, Nancy Griswold, the chief administrative law judge of the Office of Medicare Hearings and Appeals, said in an interview.

Requests for hearings increased “so dramatically and so quickly over the past four or five years — during a period of time when our adjudication capacity was not able to keep up for funding reasons — we were drowning” in appeals, she said. “It is not quite as bad right now, but we are unable to keep up with [those] that are coming in the door.” [Continued]…

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FAQ: Hospital Observation Care Can Be Poorly Understood And Costly For Medicare Beneficiaries

By Susan Jaffe | September 4, 2013 | KAISER HEALTH NEWS

Some seniors think Medicare made a mistake. Others are just stunned when they find out that being in a hospital for days doesn’t always mean they were actually admitted.

Instead, they received observation care, considered by Medicare to be an outpatient service. Yet, a recent government investigation found that observation patients often have the same health problems as those who are admitted. But the observation designation means they can have higher out-of-pocket expenses and fewer Medicare benefits. Here are some common questions and answers about observation care and the coverage gap that can result. [Continued here]

FAQ: Medicare Beneficiaries May See Increased Access To Physical Therapy Or Some Other Services

June 25, 2013

By Susan Jaffe | June 25, 2013 | Kaiser Health News in collaboration with

For years, seniors in Medicare have been told that if they don’t improve when getting physical therapy or other skilled care, that care won’t be paid for. No progress, no Medicare coverage — unless the problem got worse, in which case the treatment could resume.
This frustrating Catch-22 spurred a class-action lawsuit against Health and Human Services Secretary Kathleen Sebelius. In January, a federal judge approved a settlement in which the government agreed that this “improvement standard” is not necessary to receive coverage.

“This will help a lot of older or disabled people who clearly need the skilled care and aren’t getting it because they will not get better,” said Margaret Murphy, associate director of the Center for Medicare Advocacy, which helped bring the lawsuit. “The settlement recognizes that Medicare will pay for care to maintain their condition and prevent backsliding.”

Yet providers may not know about the settlement yet and may still be telling patients, incorrectly, that Medicare won’t cover treatment if there’s no improvement. MORE

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Advocates Head To Court To Overturn Medicare Rules For Observation Care

By Susan Jaffe | May 3, 2013 | KAISER HEALTH NEWS produced in collaboration with

Lois Frarie and her husband Wayne live in a Park Lane senior community home in Monterey, Calif. (Photo by Jay Dunn/The Salinas Californian for USA Today.)

After Lois Frarie, a 93-year-old retired teacher from Monterey, Calif., spent four days at a local hospital while being treated for a broken elbow and pelvis, she went to a nearby nursing home to build up her strength.

But her family was stunned to find out that they would have to pay thousands of dollars up front since two of the days she spent in the hospital were considered “observation care.” She wasn’t an admitted patient for at least three consecutive days and therefore she didn’t qualify under federal law for Medicare’s nursing home coverage.

Advocates for seniors say the distinction is not fair to patients.

They are taking their argument to federal court in Hartford, Conn., Friday for the first hearing on a lawsuit seeking to have Medicare eliminate the observation label. Government lawyers argue in court filings that Medicare considers observation care an outpatient service and if elderly patients think they should have been admitted to the hospital, they should file an appeal. [Continued in Kaiser Health News, and in USA Today PDF or online.]

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Medicare Seeks To Limit Number Of Seniors Placed In Hospital Observation Care

By Susan Jaffe | May 3, 2013 | KAISER HEALTH NEWS in collaboration with

Medicare officials have proposed changes in hospital admission rules that they say will curb the rising number of beneficiaries who are placed in observation care but are not admitted, making them ineligible for nursing home coverage.

“This trend concerns us because of the potential financial impact on Medicare beneficiaries,” officials wrote in an announcement April 26. Patients must spend three consecutive inpatient days in the hospital before Medicare will cover nursing home care ordered by a doctor.

…The reaction from patient advocates, doctors and hospitals has been swift and surprisingly unanimous: it’s a bad idea. MORE