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The Politics of Health Care

Observations Days: Is It Inpatient or Outpatient?

Published March 12, 2013 8:14 AM by Michael LaMagna
I want to revisit the topic of Hospital Observation Days. This is a poorly understood concept and one that I receive many questions about.

If you have Medicare, Part A and you are admitted as an inpatient for three overnight stays, on the fourth day your Skilled Nursing Benefit would be active, and if admitted to a nursing facility, Medicare would pay for up to 100 days of rehabilitation and skilled nursing. The benefit period pays 100% of the nursing costs for days 1 to 20 and there is a co-pay of $148 per day from day 21 to 100. This part is relatively uncomplicated; however, this isn't the end of the story.

Whether you are inpatient or outpatient during your stay at the hospital is critical. Although you are staying overnight, that doesn't necessarily mean you are an inpatient, and very often you are considered under Observation, which is outpatient status and not counted toward the three night qualifying stay, thereby costing seniors thousands of dollars for rehabilitation that Medicare would have paid for if the hospital had classified the stay as inpatient. In order to be considered inpatient you must be actually admitted to the hospital with a physician order. You are considered outpatient if your receiving emergency department services, lab tests, x-rays and the physician hasn't written an order to admit.

To protect yourself, you have a right to ask hospital personnel the status of your hospital stay, and if you don't agree, you have a right to appeal any adverse decision; however the appeal time frames are very short, in some cases 48 hours, so make sure you read all the information provided and take notes when talking to hospital staff.

This article is provided for informational purposes only. Nothing in this article shall be construed as legal advice or should be relied upon as such. Michael LaMagna is a Partner at LaMagna & Associates, PC, practicing Health Care Regulatory, Elder /Probate/Disability/Wills, Trusts and Estates, Social Security and General Legal practice in both New York and Connecticut. Michael was just appointed to the ACO Task Force of the American Health Lawyers Association. Email him at Mlamagna@nyandctlaw.com, call him at 914-437-5955 or visit Attorney LaMagna's website at www.nyandctlaw.com for more information.

posted by Michael LaMagna


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