I want to trust the hospital, but I don't . . .
October 8, 2013 12:04 AM   Subscribe

Last week, my 85 year old father suddenly began to experience weakness in his legs and severe pain in his lower back. His PCP couldn't fit him in but recommended the ER if he was in a lot of pain - he was, so Friday afternoon, my brother took him to the ER of the nearest hospital (which looks more like a resort). They wanted to check him out with an MRI, but their machine was not available (could they really only have one?) The hospital "admitted" him - or so we thought . . .

Dad was moved to the 3rd floor and into a private room. The MRI still wasn't available on Saturday so he continued to stay in the hospital, receiving what we believed was inpatient care. Sunday evening they were finally able to do the MRI, but the doctor had already left and we needed to wait until Monday for the results. GOOD news - there was no sign of fracture in his spine, so no surgery will be required. There appears to be some kind of compression that needs to be treated with physical therapy and medication. The doctor said they would discharge him to a skilled nursing facility.

BAD news. The social worker at the hospital informed us that because my father was in "outpatient status" from Friday through Monday, he's not eligible for the Medicare SNF benefit, which requires 3 days of inpatient care in a hospital before the patient can be admitted to the SNF. The hospital agreed to let my father stay for yet another night, but he'll be discharged tomorrow. He still can't bear weight on his feet, sit up or lie down without full assistance, and he is still in tremendous pain. Going home to my frail 85 year old mother really isn't an option.

I'll be going to the hospital in the morning and will ask if they can recode his status to inpatient starting from Friday night, but I don't expect a lot of cooperation. I'm frustrated that it took them more than 48 hours to perform the MRI on my father, and I'm suspecting that they extended his stay in outpatient status so that they could bill more. I'm also angry at myself for not asking more questions related to coverage and their delays in diagnosing my father. I truly feel like I was lulled into believing that this beautiful facility was providing the best care possible. I don't want to go in there pointing fingers and accusing them of wrongdoing - I really just want to advocate for my father. How should I approach this? Is there any chance that the hospital will change and essentially backdate a patient's status?
posted by kbar1 to Health & Fitness (12 answers total) 1 user marked this as a favorite
Go talk to the hospital, be courteous to them, explain the situation, and then be prepared to tell them they will be hearing from your attorney. Be prepared to have an attorney write them a nastygram. Somebody screwed up here - it was not you or your family.
posted by fluffy battle kitten at 1:00 AM on October 8, 2013 [5 favorites]

I don't understand the outpatient decision, which seems pretty off since he was in a room on the floor. But it is totally plausible they have just one MRI and it is not totally impossible (although I am a little wary) it was in use for that whole period. Contact the Patient Advocate or Ombudsman if the hospital has one.
posted by gingerest at 1:07 AM on October 8, 2013 [2 favorites]

Medicare has an appeal procedure. Each state has an organization that Medicare patients can call to have discharges and other decisions that a hospital makes reviewed. If he signed any paperwork at all, he should have been notified he has that right to appeal through that agency. Get copies of everything he signed and see if it's in there. Read about it here.

If he got all of the usual services an inpatient received he should have been coded as such. If I remember correctly, you can be a 23 hour observation patient and not be considered admitted but once you hit 24 hours (outside of just waiting in the ER for a bed to open up upstairs) it's a different ball game.
posted by MultiFaceted at 1:21 AM on October 8, 2013

Best answer: There are standard criteria used to determine if someone qualifies to be an inpatient. Interqual and Milliman are two such examples. If you don't meet those criteria for severity of illness or intensity of services then you get admitted as an observation patient. Your doctor writes the admission order for either inpatient or observation but it is reviewed by the social worker or case manager to see if it really meets the criteria as hospitals will not get paid if they admit you incorrectly. You can talk to the social worker and see if they have a full picture of his medical condition, but lots of people get this unpleasant suprise.
posted by SyraCarol at 2:47 AM on October 8, 2013 [2 favorites]

Best answer: What happened to your father is not uncommon.
posted by ThePinkSuperhero at 3:36 AM on October 8, 2013 [4 favorites]

It seems weird that he could have been in outpatient status that whole time, but observation status would be entirely possible. Make sure you check with the social worker what you'll be billed for medications, too. I think medicare patients on outpatient status in a hospital get charged for every pill they take, even if it's the same ones they have in bottles at home from the pharmacy. I think this might be easier to get sorted while he is still in the hospital, as opposed to after he is discharged, so please talk to them ASAP. You can protest discharge through medicare if you think it's inappropriate, and they would have to keep him at least another day while they review things.
posted by vytae at 4:23 AM on October 8, 2013

ThePinkSuperhero has the most likely explanation
posted by TedW at 4:48 AM on October 8, 2013

Best answer: Inpatient actually pays better for the hospital, but has criteria that must be met for medicare to pay. It is dramatically easier to admit someone to observation and retroactively upgrade them to inpatient if you discover that they met criteria than the reverse. As of this month, to admit someone to inpatient one has to provide a rationale for why they will need to be in the hospital for 2 midnights, and I don't think "waiting for the machine to work" will cut it.

These rules are an unfortunate byproduct of how hospitals can't self police or resist scamming medicare; they get a fixed reimbursement for your diagnosis and have an incentive to get you out the door ASAP. The SNF gets paid per day. The logical conclusion is to admit for BS reasons and immediately discharge to a SNF. Medicare got wise to this an instituted a rule that you can't discharge to a SNF (and get paid) without 3 midnights as an inpatient to make sure that only sick people were getting the benefit. Then we started just sitting on old people for 3 nights, so now we have the strict inpatient criteria and 2 midnights rule.
posted by a robot made out of meat at 5:44 AM on October 8, 2013 [1 favorite]

This is an issue I'm very familiar with, because I admit people to the hospital all day every day at work.

The two options are full admission and observation status. People can be admitted to observation status to wait for an MRI, but it is foolish to admit a frail elderly person to observation status because they always had to be in for 3 nights to qualify for a SNF/rehab regardless of what the imaging studies showed (I guess now it's 2 midnights).

Observation status is only for people who you expect to be admitted for <2>
It doesn't sound like they were giving bad care or that they necessarily had any bad intention, probably whoever wrote the admission order just clicked on the wrong box or thought "just admitting for MRI, no need for a full admit" (erroneous, but not a huge error). I don't work on the inpatient side but I imagine this sort of small coding mishap occurs all the time and can be changed.

What would be a serious error would be discharging him if he cannot walk. I seriously doubt that will happen - that's a major discharge no-no. Talk to the social worker. I'm sure you'll get it worked out.
posted by treehorn+bunny at 12:17 PM on October 8, 2013 [2 favorites]

Response by poster: Thanks for the link Pink! The Kaiser article was interesting and helpful. I shared it with the hospital social worker and then she seemed to take our issue more seriously. I couldn't convince the hospital to change my father's status to inpatient, but they agreed to get a second opinion on the MRI. As a result, he was transferred to another hospital with a strong neurosurgical unit and where he is now an inpatient.
posted by kbar1 at 9:35 AM on October 9, 2013

Best answer: You may have pretty much gotten your answer here, but I ran this past one of our social work/care coordinators to get a definitive response.

She confirmed that if a patient is admitted under observation status because they are not expected to stay for >24 hours, and then they do end up staying longer, they stay on observation status, but the hospital does not get paid for it and eats the cost. She told me that after about 48 hours the insurer sends a "notice of non-payment" or some such thing to notify the hospital they will no longer pay.

I wanted to add this because you mentioned thinking that the hospital was keeping your father to make more money, so to be clear - since the Kaiser article is a little vague about this - they do not get paid past 48 hours for patients kept on observation, so they have a big motivation to ensure that patients admitted under observation get discharged in the correct timeframe.
posted by treehorn+bunny at 6:07 PM on October 9, 2013

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