Fact: each year over one million Americans are denied access to the extended or skilled care services of Medicare if they are not classified as “admitted” when entering the hospital.

Seldom are we aware of this problem. The Center for Medicare and Medicaid (CMS) has come down hard on hospitals for “up coding” to “admitted” status in order to receive a higher payment for their services than they would if they were coded as “observational” status.

Follow this interview of a daughter’s first hand experience of denied Medicare skilled care for her mother because she was not aware of this Medicare issue and rule…

Daughter: In October, 2012, my mother fell and broke her pelvis in two places.

She was in the hospital for five days and received pain meds and intravenous hydration. My two sisters and I were told that she should go to a convalescent facility.

We had her placed in a convalescent facility and the first thing we were told was that Medicare would not cover the costs because she had not been “admitted” to the hospital. She was coded under “observational” only.

Interviewer: During your mother’s time in the hospital, did she receive treatment?

Daughter: Yes, pain meds and hydration. That was all.

Interviewer: She was treated, but never “admitted?”

Daughter: Yes, and she spent five days there; it wasn’t just an overnight.

Interviewer: So who ended up paying for her stay at the convalescent facility?

Daughter: Mother did; the bill was $6,900 for 30 days and we had to pay in advance.

Interviewer: That was well over $200 per day. Did she have a recovery?

Daughter: My sisters and I brought her home and took care of her; with a broken pelvis, she needed lots of bed rest. It took another two months to walk with a walker. She is still unsteady on her feet. There is now a family member with her 24 hours a day.

Interviewer: Then the lesson learned here is understanding the difference between a hospital “admittance” and an “observation.”

Daughter: Yes, that’s right. I asked the hospital after the fact that since she had a serious fall and was in extreme pain, shouldn’t they have “admitted” her? They said it would be falsifying the documents. I said, “but she was there for five days!”

Interviewer: What did they say?

Daughter: They said, “no.” It could not be changed.

Interviewer: Then there was no way of knowing that this would happen?

Daughter: We just assumed she was “admitted” to the hospital and never told anything about “observation” until we were ready to move her to the convalescent facility.

Interviewer: Were you surprised when you found out?

Daughter: We were stunned. When we brought her to the convalescent facility, we thought Medicare would cover the stay. But we paid up front instead.

Interviewer: How did you determine the cost of the stay in the convalescent facility?

Daughter: It went month by month.

Interviewer: I would suppose the facility has had situations where they did not get paid.

Daughter: Yes, I am sure that was the reason we paid up front.

Interviewer: So where does that leave you with the whole experience?

Daughter: I was disappointed with the way it was handled. Naturally, we would have rather been told right away that she was in the hospital on “observation”. At that time, we could have had a better chance of changing the status.

Interviewer: Anything else you can share about this experience?

Daughter: I want people to be sure to ask about the status – “admitted” or “observation.” It can make all the difference!