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89 yo Mom admitted to Memory Care 4 months ago. In past month she has become agressive and over past two weeks bit a caregiver who had to get a tetanus shot and attacked others. Physically strong but mentally in Stage 6 dementia--probably Lewy Body. MC center required that she be sent to geriatric psych unit to get medications adjusted so that she could be managed. They tried hard to manage in other ways for prior 3 weeks. Mom was taken to local ER; UTI, CT scan, were negative, providing medical clearance to get to psych unit as required. There were no beds available for 2 days, that turned into 3 days. MC refused to take her back until treated because she had to be restrained. She was held "in observation" with one-on-one nurse due to her trying to hurt herself and others for 3 days. Family didn't know she was "not admitted as a patient" until second day. Medicare won't pay for "observation" and her supplemental insurance won't pay unless it is a Medicare approved service. Three days in ER/ICU will cost thousands. Is this the way it is supposed to work? I am trying to get the hospital to change the code and admit, but it is doubtful they will. Any advice?

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I think she's referring to "observational" status as opposed to admitted status.   

"Remember, even if you stay overnight in a regular hospital bed, you might be an outpatient. Ask the doctor or hospital. You may get a Medicare Outpatient Observation Notice (MOON) that lets you know you’re an outpatient in a hospital or critical access hospital. You must get this notice if you're getting outpatient observation services for more than 24 hours.

The MOON will tell you why you’re an outpatient getting observation services, instead of an inpatient. It will also let you know how this may affect what you pay while in the hospital, and for care you get after leaving the hospital."

https://www.medicare.gov/what-medicare-covers/what-part-a-covers/inpatient-or-outpatient-hospital-status

I was in that situation when I had an emergency appendectomy.   One of the ER physicians said I would have the operation and follow-up on an "observational status."  I stated that I must be admitted b/c otherwise I could not pay for anything not covered by Medicare, and not only that, I would refuse to pay b/c for surgery, I felt admittance was required.

The ER doctor was unaware of those distinctions and I was admitted.
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TGinTN99 May 2021
Thank you. Very good advice.
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Who told you that Medicare won't pay for observation?

My understanding is that they won't pay for post hospital rehabilitation if they are not admitted but, the hospital bill is covered.

I would verify that the information is correct with the billing office. I could have outdated information, it has been a couple of years since I had to deal with this situation.
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TGinTN99 May 2021
Thank you. I will check to verify my information.
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Oh yeah! I think hospitals do that so it doesn’t mess with their statistics. My father had a stroke and was on "observation" for 10 days! My parents had to take out a second mortgage to pay the $12k bill.
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jacobsonbob May 2021
That's ridiculous on so many levels!
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I had the same experience with my mother that one of the other posters did. You have to be admitted to be eligible for post discharge Medicare funded rehab but there is no reason why Medicare and your supplemental wouldn’t pay for a “medically necessary” period of observation when she is already in a nursing home. Call CMS and check. We found then very helpful.
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Hospitals want to get paid. Simply remind then that Mom has no income. If they bill insurance (Medicare) improperly, Mom has no funds to pay.
They are not going to sue her, unless she has a bank account worth emptying. Does she?
If she does, pay the bill. If not, the hospital will code it properly.
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Im sure the Hospital will want her admitted asap because they want to get paid.

They probably just didn't have any room and couldn't just place her in a regular room due to her behavior.

You could check with the higher ups and tell them that there is no money and if they want to be paid they better turn it in to the Insurance Co Coded the right way to get paid.
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If your mother doesn't have the money to pay the bill, then it doesn't get paid. Unless you signed a paper committing that you were financially responsible, you have no obligation (in most states) to pay your mother's debts.
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I'd say take on the hospital and see if they won't change her status. Make sure you never sign as the responsible party on her admittance papers. Even if you get the hospital to change status to admitted - you may also take on Medicare to get them to pay if they feel it was observation only. However, considering the dx and that facility won't let mom back in until she in geriatric unit, in all reality it should be covered. Make an appointment with the Social Worker and see if he/she can be of assistance.
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Been there done that, where Mom was actually admitted due to here collapsing at the doctors office and going into shock (I forget the addition to hospital chart added when I told them what the doctors office diagnosis necessitating central line to revive Mom). Three days later the hospital (which hindsight is 20/20) they performed a C-diff test which came back positive (Mom was patient #5 on the unit...hence hindsight 20/20). Day 7 (day 3 treating for c-diff) I was told to pack her things she was going home as she was only under observation. I said No I and home caregivers were not qualified to treat and control c-diff a highly contagious disease. So I called Adult Protective Services and they agreed that it was a Health Safety Issue to bring Mom home. Hospital was furious.
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good luck. my mother fell and had a convoluted break in her arm (91) was taken to the hospital but due to her having osteoporosis they knew that surgery would not work due to the pins/screws not being held into her bones, they kept her for 3 days under "observation" also........so medicare would not pay. i didn't understand why but i guess because no iv's, no oxygen, etc......just there until a room available in NH. Thank God my mother had the money to pay for the bills (after my dad's insurance took care of the majority of them)........but she still had to pay also privately for her rehab because she never took out Part B and she was not at a "certified rehab center".........but things went okay. You can set up a payment plan and they have to accept what she can afford. don't fret over it too much......there are alot of people without insurance and as long as you try to make payments, there is not much they can do. wishing you luck.
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