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Observational Status Creates Roadblocks To Recovery For Medicare Patients

Many senior citizens believe that their insurance would cover costs related to a fall or accident; but a hidden policy – called observational care – may jeopardize their care, Reader’s Digest reports.

Elisa Roland chronicles the obstacles in getting her mother adequate care, after she suffered a fall and could not walk.  Before the accident, Roland thought that her parents were covered if anything were to happen. Both were insured with Medicare and supplemental gap insurance.

However after her mother’s fall, Roland learned about complications connected with observational status. Although not well known by many consumers, this status is not uncommon. The Philadelphia Inquirer reports that nearly 620,000 Medicare beneficiaries’ hospital stays were categorized as observational.

[A] sneaky little policy—among other secrets health insurance company won’t tell you—that keeps over 50,000 Medicare patients a year from going to rehab, according to a 2015 AARP Public Policy Institute report. It’s called “observation status.” And Medicare isn’t picking up your tab for it. That could end up being thousands of dollars for the many elderly folks who need treatment in a rehab facility. 

Per Medicare rules, a patient must have a three-night impatient stay to qualify for coverage.  However, in many instances, when patients are admitted to the hospital they are not admitted as inpatients - rather under observational status. Roland recalls, “In my mother’s case, she couldn’t walk and was in great pain, but was not admitted as an inpatient.”

When those patients go to leave the hospital and request to be placed in a rehab facility they are denied, as they do not meet the prerequisite.  This was the case for Roland’s mother.

“How can she come home?” my father asked. “I can’t care for her.” And how will she even get in the house? There were two staircases she’d have to climb in their bi-level home. I imagined both my parents falling down the stairs and ending up in the hospital.

Releasing my mother to a rehab facility without Medicare meant I needed to find an open bed on my own. Tough to do on a Saturday evening, and Medicare wouldn’t cover a medical transport home.

Luckily, Roland was able to get her mother’s denial appealed and get her the care she needed.  At the moment, not all are that lucky.

“People call in dire situations, and we have to tell them there’s no way to challenge this,” said Alice Bers, litigation director of the Center for Medicare Advocacy, which brought the lawsuit with Justice in Aging and a law firm, Wilson Sonsini Goodrich & Rosat [.]


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