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?
"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.
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.
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.
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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