Medicare Patients Win the Right to Appeal Gap in Nursing Home Coverage
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Tag: two-midnight rule
The Jan. 25 ruling, which came in response to a 2011 class-action lawsuit eventually joined by 14 beneficiaries against the Department of Health and Human Services, will guarantee pFederal Judge Rules Medicare Patients Can Challenge ‘Observation Care’ Status
By Susan Jaffe | Kaiser Health News | March 30, 2020| This story also appeared in 
Hundreds of thousands of Medicare beneficiaries who have been denied coverage for nursing home stays because their time in the hospital was changed from “inpati
ent” to “observation care” can now appeal to Medicare for reimbursement, a federal judge in Hartford, Connecticut, ruled last week.
If the government does not challenge the decision and patients win their appeals, Medicare could pay them millions of dollars for staggeringly high nursing home bills….
“If I had gone home, I would have died,” said Ervin Kanefsky, 94, a plaintiff [in a class action lawsuit against Medicare] from suburban Philadelphia. He was admitted to the hospital as an inpatient after fracturing his shoulder in a fall. When he was about to leave after five days to recuperate at a nursing home, a hospital official told him his status had changed to observation. With one arm in a sling, stitches in the other and unable to hold onto his walker, he learned Medicare wouldn’t pay for the nursing home. [Continued at Kaiser Health News or The Philadelphia Inquirer.]
…Class-Action Lawsuit Seeks To Let Medicare Patients Appeal Gap in Nursing Home Coverage
By Susan Jaffe | Kaiser Health News | August 12, 2019 | This KHN story also ran on 
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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]
…Medicare May Be Overpaying Hospitals For Patients Who Don’t Stay Long
By Susan Jaffe | Kaiser Health News in collaboration with National Public Radio | May 21, 2014, 9:35 a.m.
The federal government may be paying hospitals $5 billion too much as a result of an 18-month moratorium on enforcement of Medicare rules that tell hospitals when patients should be admitted, an independent Medicare auditing company told a congressional panel yesterday. The controversial rules were intended to reduce the increasing number of seniors hospitalized for observation but not admitted. If they have not been admitted to the hospital for at least three consecutive days, they are not eligible for follow-up nursing home coverage and may have higher out-of-pocket expenses while in the hospital. Medicare pays hospitals more for admitted patients than observation patients. MORE from NPR and Kaiser Health News …
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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]
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Medicare Seeks To Limit Number Of Seniors Placed In Hospital Observation Care
By May 3, 2013 | KAISER HEALTH NEWS in collaboration with 
“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