The Observation Puzzle: Medicare requirements regarding admission status and their consumer impact
Medicare insurance benefits can be confusing, especially when a hospital stay is recommended. Is my Part A or Part B billed? What does my secondary insurance cover? Am I an inpatient or an outpatient or a patient under observation? When a Medicare patient is admitted to any hospital, a complex series of decisions and events takes place (mandated by federal law) that impacts access to care and patient costs. You are an inpatient if your physician has written a formal order for you to be admitted to the hospital. If you are there for emergency services, outpatient surgery, lab tests, x-rays or observation services you are considered an outpatient. Sometimes someone requiring hospitalization is listed as an observation patient but is not considered an inpatient, even though they receive the same medical oversight and nursing care as inpatients. The best way to know your status is to ask your physician.
Observation status is a physician order used when the diagnosis is unclear and sometimes when the hospital stay is predicted to be less than the Medicare required two night stay to meet the benchmark of inpatient status. Observation status is also appropriate when a patient’s symptoms improve within one or two days. Those categorized as observation patients are given a MOON (Medicare Outpatient Observation Notice) at admission and financial concerns are addressed upfront. For a short hospital stay, appropriate observation status can cost less out of pocket for Medicare beneficiaries. Having secondary insurance is a wise idea and being a well-informed consumer is most important in order to receive quality, affordable health care. The Case Management Team at MMH can help guide you through the process while you are here.
Leann Tobin, Director of Community Engagement, MMH 240-7344