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Patient's hospital status can affect coverage of nursing home costs by Medicare

Tuesday, September 7, 2010; HE06

How do I know what my hospital status is?

Ask your doctor or other hospital officials if you are in the hospital for observation or as a regular inpatient. If you are an observation patient, ask why. Even if you are admitted as an inpatient, the hospital can switch you to observation status; in that case, the hospital is required to notify you.

If you do not have three consecutive days of hospitalization as an inpatient -- excluding the day of discharge -- Medicare will not cover a subsequent stay in a nursing home. For those who do qualify, Medicare pays for up to 100 days of rehabilitation or skilled nursing care.

How long can the hospital keep me for observation?

Medicare expects patients to remain in observation status for no more than 24 to 48 hours. But there are no rules limiting the time; some patients spend several days in observation.

What can I do if the hospital won't change my observation status to inpatient?

"You cannot directly appeal the hospital's determination that you are or were an observation patient," says Ellen Griffith, a Medicare spokeswoman.

If you think you should be considered an inpatient, ask your personal physician to call the hospital and request a change in status, although your doctor cannot mandate this. If that is not successful, there are other steps you can take.

If the nursing home or hospital says Medicare won't cover my nursing home stay, what can I do?

Ask the nursing home to bill Medicare when you enter the facility, Griffith says. Medicare will deny the claim if you do not have the required three inpatient days. The next step is to appeal that decision to the Medicare billing contractor, which will probably also deny your request. You can then appeal that decision.

If the nursing home won't bill Medicare, the Center for Medicare Advocacy, a public interest law firm, recommends that you complete a "Notice of Exclusions from Medicare Benefits: Skilled Nursing Facility" form. Ask the nursing home to submit it to Medicare to get a decision about coverage. The nursing home will not bill you while you wait for a response.

You can also question your Medicare Summary Notice, which is the explanation of benefits, says the advocacy center's Toby Edelman. It probably will show limited coverage -- for rehabilitation services -- instead of a full nursing home benefit. You can appeal to the Medicare billing contractor for full nursing home coverage, which generally is denied. To appeal that denial, follow the instructions in the Medicare Summary Notice, says Griffith.

If Medicare ultimately does not pay the nursing home, you will be responsible for the charges.

-- Susan Jaffe

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