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To Medicare Language, is Everything

To Medicare Language, is Everything

In April, Alison Kodjak, Health Policy Correspndent for the NPR Science Desk wrote about her mother's experience after a fall.

"This is a story of how money, outdated laws and federal budget rules can interfere with patient care and leave elderly patients vulnerable."

There are words that trigger fear in us all, but to deal with the maze of medicare rules and regulations and what is and what is not covered even a well informed science journalist can get caught. When Ms. Kodjak brought her mother to the hospital,

"An ER doctor there examined her, saw that she couldn't move her leg, couldn't really even hold her body upright and had trouble with her memory. He said he would admit her to the hospital's observation unit to figure out what was going on. He mentioned she might need rehab care to get up and walking again.The word observation triggered an alarm deep in my brain. I had read that patients on observation status sometimes weren't eligible for rehab care, and I told the doctor that I was concerned." He reassured her that "he and the hospital "do all they can to be sure their patients' care is covered."

You can probably see where this story is going. Ms. Kodjak had to write an up- front $12,000 check to get her mother admitted to a rehab center.  

This was due to:

Her mother being" caught in an administrative wonderland where she slept at a hospital for four nights, but the paperwork said she was an inpatient only one of those nights. Medicare's rules, dating back to the 1960s, require people to spend three nights in a hospital before the federal program will pay for inpatient rehabilitative care."  This is where the tale goes from bad to worse.

Rules and Regulations, not patient care, are the standard procedure.

"The doctor couldn't admit her as an inpatient because she didn't have a qualifying diagnosis.Her status was changed from observation to inpatient on the third day because Medicare requires that. They could not change her status to inpatient for the entire stay because they didn't want to be audited.She couldn't go to acute rehabilitation, which Medicare pays for, because there was no evidence she had had a stroke or heart attack." 

After having to take a home equity line of credit to come up with the cash to help her mom, Alison writes here is what she learned.

"Medicare, in its zillions of pages of guidelines and regulations, has two competing rules. The first says patients must spend three nights as a hospital inpatient to qualify for inpatient rehabilitation or skilled nursing care once they're discharged. The second encourages hospitals to keep patients on observation status or risk being audited.

The reason? "Medicare pays more for short inpatient stays than short outpatient stays. But once a patient has been at the hospital for a number of days, that calculus flips, and outpatients end up costing more. So in its effort to control costs, Medicare forces hospitals to justify their decisions about inpatient and outpatient status."

Ms. Kodjak's reporting continues: "the hospital still has to follow Medicare's rules when it comes to inpatient and observation care."

"There's really no financial advantage to us except if we get the status wrong," according to Yancy Phillips, the hospital's chief quality officer, "Medicare has come back to us and said, 'No, no, no, this should not have been an inpatient.' "When that happens, Medicare pays nothing at all." 

To avoid losing money, many other hospitals, use "decision support" software ... that guides doctors or case managers in making the call on whether a person should be admitted or kept on "observation."The programs are designed to ensure that hospitals don't get dinged by Medicare for overcharging or providing inappropriate services."

Again rules and regulations plus data over healthcare. 

The story ends predictably enough:

Two weeks into her rehab therapy her "mother fell again. This time, she broke her hip and needed hip replacement surgery. Because she didn't stay the whole month getting rehab care, I got a refund of about $6,000.Under Medicare's rules, that surgery meant she was automatically eligible for post-surgical rehab care. So after she was released from the hospital, she went to a new center — no deposit required."

When will Congress clean up Medicare rules and regulations ... time is of the essence we are not getting any younger!

...and I can't help wondering what would have happened to Alison Kodjak's mother had there been no money for the rehab hospital?

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