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Old 10-01-2011   #1 (permalink)
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Any Medicare Smart Folks Around?

Dad's been in hospital since Monday evening...had a seizure. Friday, I get a call from the assisted living facility that the hospital is trying to release him back...the director said he's not ready to be back, that he needs some rehab. Now the whacky part...the hospital admitted him in an observation status instead of inpatient. That means follow on rehab will not be covered under Medicare. THEN, yesterday (after I thought we had made some inroads), the discharge coordinator presents me with a hospital non coverage letter saying since he's been there all week as observation, Medicare also will not be covering this stay!!!

The man was in full seizure going into the E-room. He continued seizing from 7:30 PM to 2:30 AM...yet for some reason, they think he only had a 10 minute seizure while still at his apartment. Both the admitting doctor (hospitalist) and the Neurologist were totally surprised when I said this to them yesterday! They were basing their decisions off input from dad...who has lost a week of his life (has no idea what happened)!

So, today, I have to call an arbitration agency and try to get them to reverse the decision.

I find it hard to believe ANY medical provider would 1) just place a seizing patient in "observation" status 2) keep them for a week. 3) continue to conduct tests (EEG etc) if he's only being observed!


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Old 10-01-2011   #2 (permalink)
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Wow Mike, I really can't offer any advice except that it just doesn't make sense! I hope you can resolve this, since you would be looking at one hugh bill.

Will pray things work out and your dad is okay also.
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Old 10-01-2011   #3 (permalink)
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Originally Posted by horizon200 View Post
Dad's been in hospital since Monday evening...had a seizure. Friday, I get a call from the assisted living facility that the hospital is trying to release him back...the director said he's not ready to be back, that he needs some rehab. Now the whacky part...the hospital admitted him in an observation status instead of inpatient. That means follow on rehab will not be covered under Medicare. THEN, yesterday (after I thought we had made some inroads), the discharge coordinator presents me with a hospital non coverage letter saying since he's been there all week as observation, Medicare also will not be covering this stay!!!

The man was in full seizure going into the E-room. He continued seizing from 7:30 PM to 2:30 AM...yet for some reason, they think he only had a 10 minute seizure while still at his apartment. Both the admitting doctor (hospitalist) and the Neurologist were totally surprised when I said this to them yesterday! They were basing their decisions off input from dad...who has lost a week of his life (has no idea what happened)!

So, today, I have to call an arbitration agency and try to get them to reverse the decision.

I find it hard to believe ANY medical provider would 1) just place a seizing patient in "observation" status 2) keep them for a week. 3) continue to conduct tests (EEG etc) if he's only being observed!


Signed
PO'd!
This is the part I don't understand. If he was seizing for that long, and upon entering the hospital, wouldn't the doctors and staff have a record of this? Why would they base their assessment on what he said after this episode? Do you have access to his chart from this time period?

eta: I hope that your Dad is okay.

Last edited by melliedee; 10-01-2011 at 10:09 AM..
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Old 10-01-2011   #4 (permalink)
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The whole system is frighteningly complex, and to achieve a reversal seems to require a full-on assault by you. I think I would start by seeking assistance from my local Elder Affairs people. I know there are legal advocates that can help unravel the rules and regulations. I am so sorry that you are going through this, and I know that any day the same thing could happen to any of us who have elderly parents. Hang in there and good luck.

Edit: oops...I forgot to say that I hope your father is much better now, the most important thing.
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Old 10-01-2011   #5 (permalink)
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First, I'll add my wishes for a quick and full recovery.

This doesn't sound like a Medicare issue - at least not yet. Medicare has to use the information given to them by the hospital in determining whether or not there is a legitimate claim for benefits. Unfortunately, this brings it back to working with the hospital in order to change the status of the admission records. Medical charts for your father should show the duration and type of seizure and any efforts to control or end it. I would question the hospital's reasons for keeping a patient in observation status for a week too. It does seem unlikely when surgery patients are often discharged in hours to avoid offending insurance regs. The hospital gets a lot more money from you for observation than from medicare for inpatient care.

Have you checked with the assisted living facility to see what their records show? There could be valuable information there also.
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Old 10-01-2011   #6 (permalink)
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The hospital screwed up and did not code or admit the paperwork correctly ...it is my understanding that anything over 24 hours is not considered "observation or out patient". Raise hell with the hospital and have them resubmit.
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Old 10-01-2011   #7 (permalink)
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The hospital screwed up and did not code or admit the paperwork correctly ...it is my understanding that anything over 24 hours is not considered "observation or out patient". Raise hell with the hospital and have them resubmit.
I agree, how could he be there a week and not be considered "inpatient".
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Old 10-01-2011   #8 (permalink)
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Usually to be considered an observation patient the stay has to be under 24 hours. Once they exceed that it becomes inpatient.

Tammy is right about the hospital not coding correctly. Have you contacted the patient advocates office there? They may be able to help you out.
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Old 10-01-2011   #9 (permalink)
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Left Dad a couple of hours ago...he's doing quite well.

They changed his status to Inpatient last night. They also increased his meds (as mentioned above). I had a sit down withthe hospitalist that admitted and told hime 1) I want him to remain in for the next few days while they watch what the increase in meds do. 2) I want an ammendment to the chart that shows he continued siezing through the night and not just eh 10 minutes at the assisted living facility that they show. He told me he had no been told about that when he was called to give admitting orders. When he was called, he was told Dad had finished siezing, had been given adivan and was resting comfortably!
I also talked to the Quality Insight Organization (arbitration for claims). They are requesting a copy of the records to review. I explained the oversight and she also said make sure the doctor adds an ammendment.

They are keeping him at least through Monday...that will, as mentioned ensure he's watched with the new meds and two will have the magic 3 days in patient to unlock his medicare part A for rehab.

I will also be calling the State Ombudsman to discuss and probably the hospital administator to ask how the oversight was made.

Thanks everyone!
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Old 10-01-2011   #10 (permalink)
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Mike, glad to hear things are working out and your dad is doing better.

But honestly, if he goes into a nursing home for rehab, this is where you will really need to be on your toes unfortunately.
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Old 10-01-2011   #11 (permalink)
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Mike, glad to hear things are working out and your dad is doing better.

But honestly, if he goes into a nursing home for rehab, this is where you will really need to be on your toes unfortunately.
Mercy, the Nursing home is an extension of the assisted living facility where he lives. They have a section cordoned off just for the rehab. Indications are he'll probably only be there about a week to week 1/2. But, yes I will be paying attention..thanks!


Oh and you can bet anytime a family or friend goes into the hospital from here on out, I will be asking what status they are in!
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Old 10-01-2011   #12 (permalink)
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Glad to hear he's doing better, Mike.

Your advocacy on his behalf with all these complicated issues makes me feel for older people who do not have family members speaking up for them. My grandma is currently in an assisted living center while the pins in her wrist set from a fall she had in her apartments a few weeks ago. My mom and aunt are constantly there, checking paperwork and her PT visits (there always seems to be some confusion or mistake; she is very hard of hearing and nods and smiles a lot when the docs ask her these complicated questions). I wonder how older people without family even navigate these issues?
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Old 10-02-2011   #13 (permalink)
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Glad to hear he's doing better, Mike.

Your advocacy on his behalf with all these complicated issues makes me feel for older people who do not have family members speaking up for them. My grandma is currently in an assisted living center while the pins in her wrist set from a fall she had in her apartments a few weeks ago. My mom and aunt are constantly there, checking paperwork and her PT visits (there always seems to be some confusion or mistake; she is very hard of hearing and nods and smiles a lot when the docs ask her these complicated questions). I wonder how older people without family even navigate these issues?
Mel,
It IS sad to see! The facility where Dad lives is fantastic. In fact, they are the people that alerted me to the medicare situation. They have been over to the hospital on a daily basis visiting Dad and the nursing director and facility director boh stop by and not only visit with him, but go to the nursing station and review his chart.
There have also been some very good people at the hospital helping me navigate this....some not so easy to work with. But, on the whole, they are just as frustrated by the rules as I am.
Not totally out of the woods yet, but we can see the fields that surround them!
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Old 10-03-2011   #14 (permalink)
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So, just when I thought everything was on track...the review panel called yesterday and denied the review. The physician board thought everything was done correctly.

I am going through the "reconsideration process" now. If it gets denied, I go to Medicare appeals.

I guess I'll call the state ombudsman office today.
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Old 10-03-2011   #15 (permalink)
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Mike, sorry to hear this. Will pray that you can get someone to help you with this.
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