In the beginning of 2017, Medicare implemented the new Medicare Outpatient Observation Notice which seems to have the same effect as the old ‘mooning’ we think about from American Grafitti.
You see, MOONing in Medicare (sounds like a love song from Cole Porter, doesn’t it?) means that within 36 hours of entering a hospital, if you will not be admitted, but only kept under “observation,” they must inform you with a written explanation. This is the form, if you’d like to see it!
The problem with this form is the unintended consequences it might have for you, if you are on Medicare, or your loved one, if you are a caregiver for someone who is on Medicare.
If a patient is placed under observation, typically in the Emergency Room, and is never formally “admitted” to the hospital, Part A hospitalization of Medicare does not pay. In other words, you are paying as an outpatient. For a quick trip to the ER (is there such a thing?) that’s no big deal. After all, the Part A deductible is $1340.00 so you may not even spend that much if you’re only there a few hours.
However, if you are there a few days, and you stay on observation, it is likely that you will start racking up fairly high medical costs with co-pays for every service you are getting. Not to mention any drugs, that likely will not be covered by your Part D while you are in the hospital. It’s complicated, scary and could be costly.
The worst result could be that you are sent to rehabilitation, and because you never met the “admitted to the hospital for 3 days” requirement to have Medicare pay for at least 20 days in that rehabilitation center, you are now responsible for a significant bill coming out of that rehabilitation center. This has happened to people to the tune of thousands of dollars.
So what can you do?
This advice comes directly from this AARP article, which oddly was written before MOON became a regulation and before the MOON form existed. So I have added two of my own suggestions at the end:
Medicare: Inpatient or Outpatient?
- Ask about your status each day you are in the hospital, as it can be changed (from inpatient to observation, or vice versa) at any time.
- Ask the hospital doctor to reconsider your case or refer it to the hospital committee that decides status.
- Ask your own doctor whether observation status is justified. If not, ask him or her to call the hospital to explain the medical reasons why you should be admitted as an inpatient.
- If, after discharge, you need rehab or other kinds of continuing care but learn that Medicare won’t cover your stay in a skilled nursing facility, ask your doctor whether you qualify for similar care at home through Medicare’s home health care benefit, or for Medicare-covered care in a rehabilitation hospital.
- If you go to a skilled nursing facility and have to pay for it yourself, you can try formally appealing Medicare’s decision. When you receive your quarterly Medicare Summary Notice, make a copy and highlight the facility’s charge. Send this to the address provided on the notice with a letter saying you want to appeal Medicare’s decision of noncoverage on the basis that you should have been classified as an inpatient during your hospital stay and not placed under observation. If this is denied, you can go to a higher level of appeal, following instructions on the denial letter.
Additionally,
- You can refuse to sign the form. All that does is make the hospital sign it, and make them a bit testy. But it signifies that you do not accept this and hopefully is evidence on Appeal that you were trying to fight the observation status.
- You can take your patient home. I am not recommending this, especially if the whole reason you are fighting ‘observation status’ is because your patient is very sick and you are certain they will end up in the hospital, a rehab center, or a skilled nursing facility after this event. But one of the problems with Medicare is that they penalize hospitals for re-admissions. So discussing the possibility that you might take your loved one home, that might force a re-admission, may move them to admit your loved one.
Sometimes this feels like the “Art of War,” when dealing with healthcare issues. Being forewarned is being forearmed, as they say. Seems like anything is better than being MOONED!
“You Just have to Laugh…..”
©2018 Cathy Sikorski