Most times, I try to stay out of the business of explaining to laymen the nuances of health care billing issues. Probably because it always ends up with me trying to defend stupid insurance rules, which is not a point of strength for me.
But this one really has my hair up. And the public should understand this nuance. So here you go, public:
"We're going to admit __________."
Fill in the blank with you, your wife, your husband, your mom, dad, grandma, son, daughter...etc.
Upon hearing these words from a doctor, most are overjoyed that FINALLY someone is listening and they've decided to put ________ in the hospital!
We are going to get answers! He/She is not just making it up! Ugh.
Cell phones blaze in a moment of glory.
But let's pause the video here for a moment, Bob, because there is some vital information missing:
Let's review:
"We're going to admit ________ to observation."
"We're going to admit ________ to inpatient."
See those two words at the end? Those two words mean everything when the bill gets calculated and the amount owed by the patient is tallied.
Because of the fairly recent CMS (Centers for Medicare and Medicaid Services) two midnight rule, when evaluating a patient, doctors must determine whether or not he or she thinks the patient will require less than a two day stay or at least a two day stay.
If less than two day, the patient is placed in observation. If more, the patient is placed in inpatient. (And don't get me started on Condition Code 44. That is yet another post.)
Observation means outpatient status. Yes, you or your loved one is in the hospital, but did you know that you can be considered an outpatient yet still be in the hospital? Maybe not.
Inpatient means really, truly, and most assuredly in the hospital and likely to visit many a step-down unit like cardiology, pulminology, ICU, etc.
This all matters because of how insurance will pay.
Insurance plans pay based on whether or not the service is provided under outpatient rules or inpatient rules.
While I am reluctant to provide a dissertation on every insurance carrier known to man and Obama Care, please know that those two simple words make a difference.
It's important to ask your admitting physician whether ________ is being admitted to observation or inpatient status and to also ask WHY.
Although, I am quite sure that after 1mg of Dilaudid the patient won't care, and neither will the family because the bitching has finally stopped, but anyway. ASK.
Then you attain a position of knowledge and hopefully won't have a heart attack upon receiving the bill which will then put you in the hospital under either outpatient observation or inpatient status.
This has been a Public Service Announcement. Thank you for your time.
Pleas, on all that is holy(and unholy for that matter) please, please, please do not ask patients to ask doctors if we are admitting them inpatient or observation.
ReplyDeleteWe don't know. The rules are made up and change every 3rd Tuesday unless it is after 2pm in a summer month unless of course the IV fluids are going at 79.4ml/hr or quicker.
I defer all inpatient/obs questions to the only person who has the foggiest clue, and they are wrong often enough. That is the coders.
OR if you must ask me if I am admitting you for inpatient or observation understand that this will be the answer,: "I am admitting you (A) because that seems to be what was ultimately decided by the people who decide such things last time I admitted someone with similar problems to you. Now admittedly, the time before that it was (anti-A). In reality, we'll only know for sure which way you were admitted about 90 days from now'
ReplyDeleteHaha! Yep. Maybe not one of my better ideas. But I stand by it. There needs to be more transparency for patient cost in healthcare across the board.
ReplyDeleteTruthfully, even the coders don't know! I've had to re-code entire visits after a UR. Not fun.
Thanks, Kassy!
Well, it might be different for Medicaid/medicare, but on my insurance, if I end up in the hospital, I will owe the difference between what I've already paid in cash so far for the year, and my out-of-pocket max. No matter whether it's inpatient or out, once I hit that out-of-pocket max, I don't have to cough up any more money until January.
ReplyDelete