Why Won't Medicare Pay?

Most of us have heard about, and think we understand, the “three midnight rule for Medicare.”  Either way, let’s review it.  When a patient is admitted to a hospital and ultimately will be sent to a skilled nursing facility for rehabilitation, Medicare will only cover its share if the patient spent three inpatient midnights at the hospital and was discharged directly to the skilled nursing facility (SNF).  In that phrase, the word “inpatient” is as important as the three midnights required to be in the hospital.

When a patient is admitted to the hospital, the hospital/physician has two basic options.  They can write an order for inpatient status, or for “observation status” which is an outpatient category.  The three inpatient midnight rule means Medicare will pay for SNF benefits only if the patient has been in the hospital three midnights, as inpatient status.  Be advised, if the patient is in the hospital three nights under observation status, there is no Medicare coverage of the SNF.

In 2014, Pennsylvania enacted a state law which requires the hospital to provide the patient with a notice of observation status if the patient receives services for more than 23 consecutive hours.  See Act 169 of 2014.  The Notice Act passed by the federal government, which became effective in August of 2016, is similar to Pennsylvania’s current state law.

The current and new laws don’t eliminate the issue, but it is a step in the right direction.  However, in a time of crisis, one more piece of paper serving as a “Notice” may easily go ignored.  The moral of the story is to check patient status immediately and then confirm it.  If the hospital won’t change the status to inpatient after contacting the patient’s physician for help, you have two choices prior to discharge: contact an attorney for assistance, or change the care strategy.  Some families may decide to receive different medical services after being informed of observation status.

If you would like to learn more about Medicare or protecting assets from long term care costs, please contact Attorney Ken Potter at RHP Law Group LLC, 1372 North Susquehanna Trail, Suite 130, Selinsgrove, Pennsylvania  17870; Phone: (570) 743-2333 OR toll-free (888) 505-6115; or Email [email protected].