Quote:
Originally Posted by Kobi
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?
|
Thank you Kobi for stepping in and clarifying, it's important that folks have accurate information.
I have only my own experiences and the bits of reading about some of these situations experienced by others to go on.
I should have said upfront that I am certainly no authority on the subject. It's reassuring to know that Medicare part B helps with this as I'm sure it won't be my last rodeo in "observation". My mother has parts A, B, D, and medigap as well, this has been so good that there have been no significant bills over these last couple of years by the time things get processed. Something I have found is that even though there is little to pay, I do want to examine the bills in detail to check for errors, and to find out what is actually going on. Her town hospital has taken to sending bills that say "IP Inpatient" half a dozen times with differing $ figures for each line. So even though most of the bill is paid and I just get the little remainder I have established with them that I will not pay any bill until I get the detailed version, I have to call them for every bill, but they can look up the account and have accepted my terms.
Thank you also for the information on the Medicare advocacy center as I am trying to see if there is recourse for another situation involving skilled nursing this last go round and you are right, that's a whole other kettle of fish. Two years ago I couldn't get my father out (he had a crappy physicians directive), and two months ago I couldn't get my mother in costing her 100 days of room and board benefits she should have been entitled to during rehab, we are out of pocket right now. She is in a private care situation that does not accept insurance of any kind, it is very good and she will now stay there going forward, it would be nice to get reimbursed for what she should have been eligible for though. The whole town was full beds and the hospital wanted her out but there was nowhere to go. Fortunately, I spent quite a bit of time with a lawyer crafting a medical proxy that is extensive and covered every situation I had so far experienced and some others recommended by the geriatric care manager I have on retainer in case something happens to me so that she can take over. I have had to confront the hospital twice with this so far and the roadtest has worked. I now have the same proxy in place for myself.
I know you say this is not insurmountable and I agree IF you have someone with a clear head helping with or doing this part of it. This scares me for the elderly in general and myself in particular. My mother has dementia and there is no way she could even comprehend the maze much less deal with it. For myself I wonder about if I were to be badly injured or very sick, maybe drugged, and not understanding and maybe missing some deadlines or such. I am looking into maybe bringing a conservator onboard to handle my finances if I am disabled/incapacitaed with the accountant as a check/balance in that situation.
This is all damn complicated and underscores the phrase "Gettin' old ain't for sissies"!