Medicare and Hospital Stays: Are You an Inpatient or Outpatient? You Need to Know

A lot has been written recently about the difference between being considered an inpatient or outpatient when it comes to hospital stays and what medicare will and will not pay for.  And, the difference could greatly impact what you owe.

Note: if you have a Medicare Advantage plan or other insurance, your cost and coverage may be different.

Inpatients vs. Outpatients

According to medicare.gov, you are considered an inpatient when “you’re formally admitted to the hospital with a doctor’s order.” And, you are an outpatient when you are “getting emergency department services, observation services, outpatient surgery, lab tests, x-rays or any other hospital services and the doctor has not written an order to admit you as a patient.” In fact, you can be considered an outpatient even if you spend a night or more at the hospital.

What about “Observational Services?”

One of the more challenging parts of this definition is that of “observation services.” Observation services can take place anywhere within the hospital, however, many usually stem from a trip to the emergency department where a patient can be placed on observation status so that a physician can evaluate whether an inpatient stay is warranted.  The challenge with this is that although you may be in a hospital gown with an ID bracelet, receiving hospital care, and potentially spending a night or two under observation, you are not considered an inpatient.  This is where it gets tricky.

Medicare Coverage for Inpatients and Outpatients

For inpatients, Medicare Part A covers inpatient hospital services with Medicare Part B covering most of your doctor services (paying a one-time deductible for Part A and 20% of the services and a deductible for Part B.)

For outpatients, Medicare Part B covers the outpatient hospital services, the caveat being that you pay a copayment for each individual outpatient hospital service, and the amount can vary based on service provided.

But wait! It gets even trickier if you require a skilled nursing facility (SNF) after your stay.  Medicare will only cover care you receive in a (SNF) if you have a qualifying inpatient hospital stay.  Medicare states that “A qualifying inpatient hospital stay means you’ve been a hospital inpatient (you were formally admitted to the hospital after your doctor writes an inpatient admission order) for at least 3 days in a row.” This 3 days counts the day you were formally admitted but not including the day of discharge.

If you were in the hospital under observation and it was determined that you needed a SNF, your outpatient status means that Medicare will not pay for SNF.  Even if you were in the hospital for a day under observation and then admitted as an inpatient for two days, you would not meet the 3 day “inpatient” requirement for Medicare to pay.

So what can you or your family members do?

• Always ask your doctor or the hospital staff if you are considered an inpatient or outpatient.
• If you are in the emergency room or receiving services for longer than a few hours, let the medical staff know that you would prefer that continued treatment be done on an in-patient basis.
• If SNF is needed, ask if Medicare will cover the stay.
• Ask if you can get care in other settings such as home health care.
• Ask if other programs such as Medicaid or Veteran’s benefits might cover some SNF costs.
• Request to speak with the hospital social worker to help determine your options and costs involved with the options.

Sources:

• medicare.gov – Are you a Hospital Inpatient or Outpatient?
• Central Texas Caregivers – Medicare and Inpatient vs Outpatient Treatment Costs
• Healthcare Reform Magazine – Inpatient vs Outpatient Observation Hospital Status
• Wall Street Journal – Beware Medicare’s Observation Status
• AARP – Medicare: Inpatient or Outpatient?
• Centers for Medicare & Medicaid Services – Inpatient Hospital Reviews

A Place at Home offers R.N. Care Coordination services that can help you through some of these situations.  We have found that families, especially those who do not live in the same immediate area as their senior, are relieved to have someone they can trust and who knows the ropes of the medical industry to assist seniors through these times when an advocate is truly necessary. Contact us today for more details.