ER Medical Care and Health Insurance Roulette
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Know the fine print of your Medicare/Insurance
Recently I took a loved one to the Emergency Room. Her blood pressure was high and she had a bloody nose that had been going on forever. On the way to the ER, the bleeding began to slow down, but since the BP had been high, we decided to continue on since it was late and our doctor was out of town.
We arrived shortly before midnight and signed in. About 1:15 a.m. they called us in to register her and then at 1:45 another member of the hospital staff requested her Medicare and Insurance cards. She was given papers to sign as normal, but along with the returned medical cards, we were given a form letter that informed us tht Medicare had made changes last year and that they and other insurance companies classify an observation stay as an "outpatient" visit. Because of this fact, the form stated that both Medicare and your insurance company will hold you responsible for co pays and deductibles that would be associated with an outpatient stay. Additionally, the form letter stated that Medicare no longer provides coverage for most drugs administered as an outpatient and that you would be billed by the health center for these "self-administered" drugs. The form also stated that you could get your physician to write an order that it is alright for you to bring your own medications from home while being observed. I guess this is another note we need to add to our Emergency file.
I wanted to learn more about this situation, so first I visited Medicare and it didn't take me long to find the information on self-administered drugs. In Your Guide to Medicare Prescription Drug Coverage I found:
Note: Generally, self-administered drugs you get in an outpatient setting (like an emergency room, observation unit, surgery center, or pain clinic) aren’t covered by Medicare Part A or Part B. Your Medicare drug plan may cover these drugs under certain circumstances. You may need to pay out-of-pocket for these drugs and contact your plan to get back some of the cost. Call your plan for more information.
In the Medicare Glossary, I discovered how they define Observation Status:
Medical or surgical care furnished by a hospital to you if you have not been admitted as an inpatient but are registered on hospital records as an outpatient. If a doctor orders that you must be placed under observation, it may be considered outpatient care, even if you stay under observation overnight.
At AISHealth.com, I found a table that you can access that addresses the situation here.
I learned more by visiting other sites who have been talking about this change. They refer to it as code 44 billing.
Observation with condition code 44 and physician supervision ...
Last week the American Health Lawyers Association held their annual Institute on Medicare and Medicaid Payment Issues in Baltimore. After speaking about observation at a conference session, I had the opportunity to speak to a CMS ... When the case is converted to outpatient under condition code 44, I indicated it was unclear if these hours should be converted to observation or if the observation time begins at the time the inpatient status is changed and the observation ...
Manual changes related to condition code 44 | Case Management Blog
To be billed to Medicare they would have to meet all the coverage and billing requirements, just like the x-ray. This is where the new changes to the observation section of the manual perhaps add a bit of clarity, though the issue is still not ... They eliminated any notion that observation was a status and emphasized that it is simply an outpatient service in their view. Therefore, in CMS' view the patient can't be in observation status, instead they are converted to ...
Inpatient or Observation, Now That is the Question | Case ...
Medicare does not specify what type of bed or unit a patient must be in if they are observation status. Medicare coverage for observation services requires at least 8 hours of monitoring. Observation time begins at the time the ...
Condition Code 44 – Let's focus on process | Revenue Cycle Institute
Last week, Kimberly Hoy, director of Medicare and compliance for HCPro, Inc, brought up some additional questions about the conversion of inpatient hours to observation time, following a Condition Code 44 change of inpatient status to ...
Condition code 44 and counting observation time | MedicareMentor Blog
When a hospital follows the CC 44 change of status process, it is able to convert the inpatient stay to outpatient care. Presumably, that means that the hospital can go ahead and bill the services provided to Medicare during that ...
NGS statement on billing condition code 44 | Case Management Blog
We received confirmation from our CMS representative that indeed, a written order for observation status is required and that the inpatient stay can not be converted to observation time when CC 44 is applicable. ... The Medicare Manual states the entire episode of care should be billed as an outpatient under condition code 44. That is why many hospitals are making the effective date the time of the admission with the condition code attached to the claim. ...
In their infinite wisdom, the Medicare rule makers continue to plague the hospital industry with on-going information about observation services vs. inpatient admission. It was a mess when first introduced as 'observation status' and it .
I have added the RSS feeds of the above blogs to my feed reader so that I can at least try to stay on top of changes that may occur and be the best advocate I can for those I'm caring for.
