[Kobi]

Originally Posted by Kelt

Hey girl_dee

I'm sure you already know this, but just in case and if others don't, find out if she has been admitted or if she is there for observation. Hospitals love to play the observation game, high profit for hospital retail. I went through this with my mother about 9 months ago. Admitted=covered by medicare, observation=out of your pocket. In my mothers town observing is $5k per day and they want her for 3 days/2 midnights.

In our case they "observed" her so well that she was too dehydrated to kick out (4 hours notice/8pm before the 3rd midnight) they had to admit her and the bill got covered, but it was a close call.

They admitted her for a broken rib which she did not have. The bill was $21k, after all her insurances we paid about $400.

Kelt, a point of clarification here. Admission is covered under Medicare part A. Observation is paid under Medicare part B. Medications may not be covered under observation with part B but they are under Medicare part D.

Insurance is a game. You have to understand the rules to play it well.

One of the biggest things to remember is the billing portion is often decided after the fact by coders who may or may not know what they are doing.

Another thing to keep in mind are the multitude of rules regarding readmissions/reobservations within certain periods of time. The "re" part says to Medicare you were not treated properly to begin with. That is an internal billing issue between the facility and medicare. If a facility tries to make it your problem, dont buy into it.

Never pay a hospital bill that doesnt sound or look correct. Call and ask questions. Billing cycles do not always coincide with reimbursement cycles meaning bills get generated erroneously simply because of timing.

If the issue is still not resolved, call and double check what you were told with medicare itself - every state has an organization that administers medicare. They can interpret the bill in conjunction with the rules. This usually resolves issues and makes bills disappear.

The center for Medicare advocacy, completely separate from the actual insurance process is the best resource if you need to know the route to dispute a bill if the above doesnt solve the problem.

Another avenue is to call your congressperson for help. Their offices have differently avenues to circumvent the game of insurance. Plus, it helps to keep them aware of the unintended glitches in stuff they approve.

The bigger thing to watch for is the 3 day rule for admission to a skilled nursing facility. You have to have been billed as admitted for this is work. Otherwise, the nursing home/rehab is not covered. That is a different set of headaches but also not insurmountable.

Just an aside, facilities cannot charge you a separate fee for a private room. They still try but it is an illegal practice. The reimbursement for your care is based on diagnosis not accommodations.

This stuff was the most fun part of my job. There is something nice about being able to say.....you know that is illegal right?