This Could Hurt…a Lot!

According to a recent Money Magazine article, there is an alarming trend emerging which is resulting in big bills for Medicare patients. This trend has to do with Skilled Nursing Facility care and Medicare’s requirements for covering it. And if a service is not Medicare approved, you are on the hook for the full bill, which could cost in the thousands of dollars. And Medicare Supplement insurance follows Medicare’s decisions, so that won’t help either. So, let’s find out what Skilled Nursing Facility care is, what is causing the problem and what you can do about it?

Skilled care is healthcare given when you need skilled nursing or rehabilitation staff to treat, manage, observe and evaluate your care. This type of care is typically given in a Skilled Nursing Facility which could also be a Long Term care facility. An example would be a patient who has undergone a joint replacement and needs to go to a facility temporarily to get rehabilitation so they can get back on their feet. If your stay is Medicare approved, Medicare fully covers the first 20 days of skilled care and all but $144.50/day for days 21-100, and many medicare supplement plans will pick up this daily copay amount giving you a total of 100 days at no cost to you. A patient in the Money magazine article had a 10-day rehab stay which was not medicare approved and she got a bill for $7,027. Of course she didn’t know this until she got the bill.

There are many requirements for a stay to be Medicare approved (which can be viewed here) but the major culprit is the requirement of a 3-day inpatient hospital stay prior to going into the Skilled Nursing Facility. The key word here is “inpatient.” The problem arises because many hospitals are beginning to keep patients under observation as opposed to inpatient, due to Medicare’s crackdown on costs (Medicare pays hospitals far less for observation than for inpatient stays). From the patient’s viewpoint there is no difference in the care you receive, so you won’t know by looks whether you are inpatient or under observation. Even if you start your stay under observation and switch to inpatient later, the observation days won’t count toward the 3-day inpatient requirement.

So what can you do to prevent this from happening? Here are a few suggestions:

  • Don’t Wait/Don’t Assume:  Your best shot at getting Medicare to cover a skilled nursing stay is to have your status switched to inpatient while you are in the hospital.  Appealing a Medicare decision after the fact is much tougher and a lengthy process.  So ask your doctor and case manager what your designation is.  If it’s observation, press your doctor to review your status and take your case and full medical history to the utilization review committee.
  • Bring in Help:  Ask your primary physician to call the hospitalist and explain what risk factors or conditions might warrant a higher level of care.
  • Arrange Home Care:  If all else fails and you can’t afford to go to a nursing facility, talk to the discharge planner.  Medicare covers a limited amount of home help, even if you weren’t an inpatient.

So, before you get blindsided by a huge rehab bill, make sure a family member is aware of these requirements and can help you should you have a hospital stay in your future.

Much of the above information was derived from the August 2012 Money Magazine article “This Could Hurt-a Lot” by Amanda Gengler.

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