What is the difference between being admitted to the hospital and being under observation? How does this impact Medicare coverage and out-of-pocket costs? Get answers to these important questions.

The Distinction Between Admitted and Observation Status

When a patient is hospitalized, it is crucial to understand the difference between being “admitted” and being “under observation.” The admitted status means the patient is formally admitted to the hospital under the care of a doctor, while the observation status indicates the patient is staying in the hospital but as an outpatient.

The distinction between these two statuses can have significant implications for the patient’s insurance coverage and out-of-pocket costs. For example, if a patient is under observation for more than 24 hours, they may incur higher copays. Additionally, Medicare coverage for post-discharge skilled nursing facility (SNF) rehabilitation is directly tied to the patient’s prior hospital stay status.

The Impact on Medicare Coverage

Medicare coverage is affected by the patient’s hospital stay status. If the patient is formally admitted, Medicare will cover the hospital stay and any post-discharge skilled nursing care, as long as the patient was in the hospital for at least three days as an admitted inpatient. However, if the patient was only under observation, even if they spent multiple nights in the hospital, they may not qualify for Medicare coverage of skilled nursing care after discharge.

This can be a significant financial burden for patients and their families, as skilled nursing care can be extremely expensive. It is crucial to understand the patient’s status and advocate for them to be formally admitted if it is likely they will need post-discharge rehabilitation.

Navigating the Hospital Admission Process

Hospitals are required to inform patients of their admission status, but this information can sometimes fall through the cracks or be misunderstood. It is important for patients and their families to be proactive in asking about the patient’s status and understanding the implications.

Hospitals often have staff, such as social workers, who can help patients and their families navigate the billing and terminology related to hospital stays. Additionally, organizations like Oasis Senior Advisors can provide free consultations to help demystify these complex issues.

Automating Criteria for Hospital Admission

One of the challenges in the hospital admission process is that emergency department clinicians, who perform the initial assessment of patients, are not always well-versed in the specific criteria for inpatient versus observation status. They may be focused on the medical needs that require hospitalization, but not the nuances of the admission process.

To address this, some hospitals are exploring ways to automate the criteria for hospital admission, ensuring that patients are properly categorized and their insurance coverage is accurately reflected. This can help avoid surprises and financial burdens for patients and their families.

The Importance of Understanding Hospital Admission

Navigating the hospital admission process can be daunting, but understanding the difference between inpatient and observation status, as well as the implications for Medicare coverage and out-of-pocket costs, is crucial. By being proactive and seeking support from hospital staff and organizations like Oasis Senior Advisors, patients and their families can make informed decisions and avoid unexpected financial obstacles during a challenging time.

Seeking Assistance and Resources

If you or a loved one is facing a hospital stay, don’t hesitate to reach out for help. Hospitals often have staff, such as social workers, who can provide guidance on the admission process and insurance coverage. Additionally, organizations like Oasis Senior Advisors offer free consultations to assist with understanding these complex issues.

By being informed and proactive, you can ensure that your loved one receives the care they need while minimizing the financial burden. Remember, you don’t have to navigate this process alone. Don’t hesitate to seek the support and resources available to you.