Patients and providers are both caught up in Medicare's Catch 22 rules. There are many, too many for 'whistle-blowers' and legislators to fix. Fix one and another pops up.
Here is one example of multiple conundrums. What ever happened to 'Precision Medicine" and "Patient-Centered Care" ? This is really all about money, and the aphorisms and politically correct mantras are a camoflage for what is embedded in the health system. The only other similar situations is government contracting for Defense and other agencies. It costs more to file for a grant and accomlish the followup paperwork than to build a product. Example: Federal Health Insurance Exchanges.
Now, on to Medicare Catch 22 rules and Skilled Nursing Facilities
It’s bad enough to be hospitalized. But thousands of seniors across the country are finding their medical problems compounded with financial frustration and large bills because of a Medicare technicality that can cost them dearly.
The problem starts when their doctors want them to go to a skilled nursing facility as an interim, rehabilitative step between the hospital and home. That’s fairly typical when a patient needs to regain strength but no longer requires hospitalization.
But if the hospital has not classified the patient properly for Medicare billing purposes, then Medicare, the government health insurer for seniors, refuses to pay the skilled-nursing bill. Even a short stay costs the patient thousands of dollars.
For Marilyn “Micki” Gilbert, 83, an assisted-living resident at Menorah Park in Beachwood, the bills came to $17,000 after more than four weeks of skilled nursing care. Following a hospital stay of several nights last August after she fell and was hospitalized “with a head broken open and sutures,” as she put it, she expected Medicare to cover her rehabilitative care.
But Medicare administrators refused. The problem was that when the hospital sent the bill to the Centers for Medicare and Medicaid Services, or CMS, for payment, it said that Gilbert was in the hospital for “observation” rather than admitted in the “inpatient” category.
That difference, which is many cases is a technicality, means the difference of thousands of dollars for every patient affected.
The hospital prefers to bill for observation the first 24 hours since Medicare will pay more than if the patient is 'admitted'. In fact hospitals have developed an intermediary 'holding area' near an emergency room where a patient will stay for 24 hours while a determination is made. It is not about the diagnosis or treatment...it's about the dollars lost to the hospital if the patient is directly admitted. And this is an issue over which doctors have no say. The hospital does the facility billing.
The problem is a result of Medicare rules that only authorize follow-up, skilled nursing care after a patient has had inpatient hospital care for at least three consecutive days. Even splitting that classification – say, as one day for observation and two for inpatient care – will not satisfy the three-day inpatient requirement, regardless of the fact that the patient stayed and was treated in a hospital the whole time.
The inspector general for the U.S. Department of Health and Human Services said that in 2012, Medicare beneficiaries had more than 600,000 hospital stays that lasted three or more nights but did not qualify for skilled-nursing facility payment. In a small share of those cases, 4 percent, Medicare mistakenly paid for skilled nursing care anyway, costing $225 million. (sic)
The distinction – observation versus inpatient — has financial consequences for hospitals as well. That may be part of the problem, say several members of Congress as well as authorities from such organizations as the American Health Care Association and Center for Medicare Advocacy. Hospitals have their own financial reasons for classifying some multi-day stays as observational.
One is that hospitals with billing mistakes can be subjected to intense CMS audits with deep financial consequences. Since 2010, CMS has used outside contractors to aggressively review admission records and seek repayment for improper admissions, according the office of U.S. Sen. Sherrod Brown, an Ohio Democrat who has repeatedly expressed displeasure for the way seniors are winding up with large medical bills.
For healthcare providers, it may be safer for many to simply classify a hospitalization as observational. That usually means they’ll get less money in reimbursement than if they coded the bill with inpatient fees, and the patients may get stuck with more out-of-pocket costs for care and prescription drugs. But for hospitals, it is better than getting hit with an audit and facing claw-back demands from CMS, health professionals say.
Hospitals may also do this to avoid Medicare penalties they can face if they have an excessive number of in-patient re-admissions within 30 days of discharge.
Part of the Affordable Care Act, the Readmissions Reduction Program started in October 2012 and was supposed to result in better care the first time a patient is admitted. Excessive re-admissions now can cost a hospital money, and many hospitals are reporting that their readmission rates are, in fact falling.
But one way to get around the risk of readmission penalties may be to avoid as much as possible the inpatient classification.
Among those pushing to change these Catch-22 rules are Brown, the senator from Ohio, and Reps. Marcia Fudge of Warrensville
Gilbert, the 83-year-old woman in Beachwood, summed it up during a telephone interview in more impassioned terms. She described calling CMS, to no avail, and asking a lawyer what she could do.
“Everybody said there was nothing they could do. It’s the law,” she said.
“It’s bad enough as you start getting older. My husband passed away about two years ago, and I can’t tell you the loss I felt.” She and Leonard had been married for 64 years.
Then she fell and was hospitalized. And “no one knew how to help.”
CMS may have its reasons. Micki Gilbert can only surmise them.
“I think it’s very cruel,” she said
A 'Very Cruel' Medicare Rule - Golden Geezers Golden Geezers
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