Saturday, October 24, 2015

Costly Facts About Medicare Observation and Outpatient Hospital Admittance

I've always been skeptical of email fowards. You know the ones, FWD: followed by some subject that holds little or no interest. However, the title on this one, Hospital Stay - Important please read, indicated a topic that interests me. So I read it.

Having recently been admitted, for medical observation, in a couple of hospitals with Medicare covering all of the hospital and doctor charges except pharmacy, I didn’t believe what the writer described.

However, after doing intensive research, I found the circumstances that made his saga ring true.

Following instructions at bottom of page 40 in the 2016 Medicare & You publication, I studied the important, lengthy explanation. Are You a Hospital Inpatient or Outpatient?

Observation in an intensive care unit, ICU, is not covered by Medicare. Scroll down to see how it applies to this man’s experience!

My advice? Study your 2016 Medicare & You book, because it spells out the circumstances under the various categories on admittance, including "observation", are not covered.

Read also, "Your Medicare coverage choices".

Although doctors would like to admit patients for treatment rather than for observation, today's Medicare rules that govern admittance prevent them from doing what they believe would be in the beset interests of their patients.

The following is the original FWD: Hospital Stay - Important please read. SENIORS BETTER READ THIS!!! from a senior gentleman in Mesa , Arizona:
"Family, Friends, Neighbors, and former Classmates, I just found myself in the middle of a medical situation that made it very clear that "the Affordable Care Act" is neither affordable, nor do they care. 
"I'll go back about seven years ago to a fairly radical prostate surgery that I underwent. The Urologist who performed the surgery was very concerned that it was cancer, though I wasn't told this until the lab report revealed it was benign.

"Since that procedure, I have experienced numerous urinary tract infections, UTI's. Since I had never had a "UTI" prior to the prostate surgery, I assumed that it is one of the side effects from surgery, an assumption since confirmed by my Family Doctor.

"The weekend of March 8-9, I was experiencing all the symptoms of another UTI. By Monday afternoon the infection had hit with full force.  Knowing that all I needed was an antibiotic, I went to an Urgent Care Center in Mesa, AZ, to provide a specimen a requirement for getting the prescription. After waiting 45 minutes to see the Doctor, I started getting very nauseous and light-headed.

"I went to the Receptionist to ask where the  bathroom was, as I felt that I was going to throw up. I was told that I would have to wait for the Doctor because I would have to leave a specimen, and they didn't want me in the bathroom without first seeing him.

"That was when the lights went out. My next awareness was that of finding myself on the floor (in the waiting room) having violent dry heaves, and very confused.  At this point, I tried to stand up but couldn't make it, and they made it very clear they weren't going to let me get up until the ambulance got there.

"By the way, when you're waiting to see the Doctor and you pass out, you get very prompt attention.

"Now, "the rest of the story", and the reason for sending this to so many of you. I was taken to the nearest hospital, to emergency. Once there, I was transported to an emergency Examination room.

"Once I had removed my clothes and donned one of those lovely hospital gowns, I finally got to see a Doctor.  I asked "what is going on?  I'm just having a UTI. Just get me the proper medication and let me go home."

"He told me that my symptoms presented the possibility of sepsis, a potentially deadly migration of toxins, and that they needed to run several tests to determine how far the infection had migrated. For the next 3 hours, I was subjected to several tests, blood draws, EKG's, and demands for specimens.

"At about 7:30 [p.m.], the nurse came back to my room to inform me that one of the tests takes 1- 2 days to complete. I asked if they [the results] could be emailed, at which point she informed me that I wouldn't need them emailed because I wasn't going anywhere. I did tell her I wanted to see the doctor because I had no intention of staying overnight.

"Now, this is what I want each of you to understand. Please read these next sentences carefully.

"The doctor finally came in to inform me that he was going to admit me.  I said, "Are you admitting me for treatment or for observation?"

"He told me that I would be admitted for observation.

"I said, "Doctor, correct me if I'm wrong, but if you admit me for observation, my Medicare will not pay anything. This due to the Affordable Care Act."

"He said, "That's right, it won't."

"I grabbed my bag of clothing and said, "Then I'm going home."

"He said you're really too sick to be going home, but I understand your position. This health program is going to hit seniors especially hard.

"The doctor then left the room and I started getting dressed.  I was just getting ready to put my shoes on when another doctor [the closer] came into the room. He saw me dressed and said, "Where do you think you are going?"

"I simply said "I'm going home."

"To which he replied, quite vociferously, "No you aren't."

"I said, "Doc, you and I both know that under the "Affordable Care Act" anyone on  Medicare who is admitted to a hospital for observation will be responsible for the bill. Medicare won't pay a cent." At which point he nodded in affirmation.

"I said, "You will either admit me for a specific treatment or you won't admit me."

"Realizing he wasn't going to win this one, he said he would prepare my release papers. A few minutes later, the discharge nurse came to my room to have me sign the necessary papers, relieving them from any responsibility.  I told her I wasn't trying to be obstinate, but I wasn't going to be burdened with the full [financial]responsibility for my hospital stay.

"After making sure the door was closed, she said, "I don't blame you at all, I would do the same thing."  She went on to say, "You wouldn't believe the people who elect to leave for the same reasons, people who are deathly sick, people who have to be wheeled out on a gurney."

"She further said, "The 'Affordable Care Act' is going to be a disaster for seniors. Yet, if you are in this country illegally, and have no coverage, you will be covered in full."

"This is not Internet hype folks, this is real. I just experienced it personally. Moving right along, this gets worse. Today I went to a [required] follow-up appointment with my Arizona Family Practitioner.  Since my white count was pretty high, the follow-up was important.

"During the visit, I shared the experience at emergency, and that I had refused to be admitted. His response was "I don't blame you at all, I would have done the same thing." He went on to say that the colonoscopy and other procedures are probably going to be dropped from coverage for those over 70."

"I told him that I had heard that the "Affordable Care Act" would no longer pay for cancer treatment for those 76 and older, is that true? His understanding is that it is true. The more I  hear, and experience the Affordable Care Act, the more I'm beginning to see that we seniors are nothing more than an inconvenience, and the sooner they can get rid of us, the better off they'll be.

"We can have an impact on this debacle by letting everyone in Congress know that their responsibility is to their constituents, not the president and not the lobbyists. We need to let them ALL know that they are in office to serve and to look after the BEST INTERESTS of "we the people," their employers, and not to become self-serving bureaucrats who serve only out of greed. And if they don't seem to understand this simple  logic, we'll fire them.

"REMEMBER: Demand [that]your hospital admission is for TREATMENT and NOT for OBSERVATION! Don't believe this? Ask your doctor.


"Lord, keep your arm around my shoulder and your hand over my mouth.”

My advice? Study these: 
Are You a Hospital Inpatient or Outpatient? and ,"Your Medicare coverage choices".
When you need help, these agencies have typically provided information about their state's SHIP programs. First, Locate your local Area Agency on Aging by visiting Elder Care Locator. Once on the site, enter your zip code or city/state, and your local agency should populate.

Also, towards the bottom of the search results, the contact information of the SHIP programs in that territory or state are typically displayed.

Another resource where you do not need to register or enroll to locate SHIP information for your locality is,

Good luck!

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