Friday, July 10, 2015

Always Ask Before Being Admitted to a Hospital ~ Am I An Outpatient? Or Am I An Inpatient?

When being admitted to hospital, no matter the reason, you will be confronted with a bewildering array of paperwork. You may be unaware that 'admitted' includes two categories -- 'inpatient' and 'outpatient.' If you have Medicare Part A, Part B and Part D insurance policies YOU SHOULD ASK - "Am I an inpatient or outpatient?"

You do not have a choice, because Medicare sets the criteria. However, you should know because being an outpatient could be costly to you. Medicare rules define medications for which you have a prescription from your doctor as "Prescriptions (Self-Administered Drugs)." As an outpatient you are responsible for payment when a "self-administered" drug is given to you from the hospital pharmacy.
"Their cost can be extremely prohibitive, and in many cases Medicare members discover an outpatient is responsible for the hospital fees for those prescription drugs too late," Rod Haynes, Centers for Medicare Medicaid Services (CMS)/ Consortium for Medicare Health Plans Operations (CMHPO) Region 10, said.
This government publication explains how it works. 

You need to be very clear about which prescription drugs your Medicare-D insurer covers, and the conditions under which they pay, or in some instances, DO NOT PAY. This is vital knowledge before allowing the hospital to remove any self-administered drugs you've brought with you. Medicare rules stipulate,
"If you bring your prescription(s) from home, we [the hospital] are required to obtain approval from your physician prior to use. In addition, a hospital pharmacist must verify and certify the medication before it can be used in the hospital. There is a small fee for the medication verification."

There is no standing Medicare rule mandating that hospitals must allow patients to bring in their prescriptions when receiving care. Individual hospitals may or may not choose to permit this practice.
Why will prescription drugs you've brought (whether you're a patient in the ER or in a hospital bed) be sent home, leaving you to take medications from the hospital pharmacy instead? In most hospitals today there is no procedure whereby you can be charged a small fee and allowed to save substantial sums; the difference between what you will be charged for the hospital pharmacy's medications and your brought-from-home prescriptions. Even though they are identical.

Sean E. Dobbin, PharmD, Director of Pharmacy, Providence Sacred Heart Medical Center & Children's Hospital, explained that hospitals use digital-coding systems, much like the bar codes on items sold in stores. Hospital digital-codes coordinate your every medical procedure, including the medications you're given.

When a nurse scans the band attached to your wrist, it must match the digital-code on the medication being given. Although hospital administrators are concerned about the resulting high cost to patients, hospitals have not yet designed an efficient method to enter prescription drugs brought to the hospital by patients into their digital-coding system.
Complexities preventing this include: How can a hospital pharmacist ascertain the patient brought prescriptions that,
  • Have been stored properly?
  • Aren't from an expired batch?
  • Are the strength the doctor prescribed?
  • Or that dosage changes haven't been made since the prescription was written?
Hospital pharmacy fees for one dose can equal or exceed the price of a thirty-day supply of the identical medication sold at your pharmacy -- a substantial difference for which your Medicare-D insurer may not reimburse you.

Many diseases require medications that are catastrophically costly, yet vital to the patient. To miss even one dose may be highly risky or even deadly, but it's up to each hospital whether or not to accept the risk/liability of a patient bringing their prescriptions from home. Before relinquishing your medications, insist on meeting with the hospital pharmacist prior to taking any medication. This way, rules can be agreed on in advance regarding your self-administered drugs, or any drugs you know your Medicare-D has restrictions for.
The Medicare Rules also stipulate, "As a courtesy, we will bill your supplemental insurance on an "assignment" basis. This means we will ask the insurance company to pay us directly. Any amount not covered by your insurance will be your responsibility."
This does not apply to medications in the self-administered category. According to a finanial counselor at Providence Sacred Heart Medical Center and Children's Hospital, Spokane, WA, it means the hospital may bill for covered medications under Medicare Part A Supplement Plan. Hospitals do not bill insurance companies for self-administered prescription drugs received from the hospital pharmacy that are covered by Medicare-D insurance. The patient is billed and bears the responsibility to file a claim for reimbursement from their insurer.
Haynes said Part D is a separate matter entirely. "While hospital pharmacies are technically permitted to contract with Part D plan, it is very rare for them to do so because of financial constraints. If a hospital is willing to submit a patient's Outpatient drug claims to his or her Part D plan for reimbursement prior to billing the patient directly, such an arrangement would be entirely up to the hospital pharmacy. There is no Medicare rule mandating that the hospital do this," he said. The patient is left to suffer the consequences – or seek relief.

If for any reason you haven't reached an agreement with the hospital pharmacy beforehand, as soon as you receive their bill for the self-administered drugs you were given as an Outpatient, promptly talk to the hospital's Financial Counselor and to the Director of Pharmacy. Explain circumstances you feel should be considered, and request an adjustment. There are 'conditions' the hospital can apply to mitigate the charges.

If you need to file a claim for reimbursement from your Medicare D insurer, obtained the Prescription Drug Claim Form from the hospital's Outpatient Pharmacy Billing Department. The hospital pharmacist needs to fill out a form for each self-administered drug the hospital has billed for. Send your claim for reimbursement from your Medicare-D insurer before that insurer's deadline; keep copies.

If your claim is denied, attach copies from  your original claim and file an appeal. If a medication is not covered under your Medicare-D policy present the facts to the hospital's Director of Pharmacy and requested a review by that department. The charges may be mitigated and dismissed because of 'conditions' that meet certain criteria at that hospital.

If your insurance doesn't cover the costs, and you fail to get remediation from the hospital pharmacy, meet with the hospital's Financial Counselor. You may qualify for financial assistance, or at least be able to arrange an acceptable payment plan.

Sources:, the Official U.S. Government site for Medicare.
Search self administered drugs to get a the (pdf) Publication, "Self Administered Drugs" It explains how Medicare covers self-administered drugs given in hospital outpatient settings.
Here you can find 118 Publications that answer Medicare questions.

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