I had received a mail pertaining to this about a week ago stating Insurance Company would not be covering expenses IF Hospital papers state---- "Under Observation. "
Now this has happened to someone I know locally. This person was taken to the hospital ER for seizures. They stayed there for 3 days having various test done. They have ample Health Ins. plus Medicare.
Now the family finds ---she wasn't ADMITTED , although staying there 3 days, but rather------" UNDER OBSERVATION. It's their
understanding they will now have to pay for those 3 days in the hospital !!
Wondering if this has happened to anyone else ?
understanding they will now have to pay for those 3 days in the hospital !!
Wondering if this has happened to anyone else ?
There have been several news stories on this issue. Seems that the insurance companies have found a loophole to avoid paying claims.
ReplyDeleteWhy would they want to risk having problems getting paid, by manipulating the status of a patient?
ReplyDeleteIF they are required to stick around, then admit it!! (pun intended)
It ha been on the internet since at least 2011 and I saw it on ABC a while back, probably Febr.
ReplyDeleteCan anybody say Obamacare. When will you people wake up? If this person voted for Obama, serves them right. If this person voted for any Democrat, serves them right. If this person didn't vote at all, serves them right! If it's any of the above, suck it up cupcake and pay your bill.
ReplyDelete*Resubmitted without source link*
ReplyDeleteHospitals, local and otherwise, will use this as a tool to circumvent the Admission Readmission Revenue (ARR) rule on a set payment for an admitted service. Hospitals will put someone under observation so they can continue to bill for each order instead of only receiving a set amount for the reason of admission. This is a loophole for care providers and not insurers.
Conversely, if a patient is admitted then the hospital may only bill for that one "reason of admission"; therefore, if they are readmitted *for any reason* within the next 30 days, the hospital will not receive a payment for any services rendered as it is considered to be part of the same episode. This is true even if a patient was admitted for heart problems and then is later admitted for a broken leg in those same 30 days - the payment will be the same regardless.
Insurers are wise to this and are probably cracking down on it.
Google HSCRC Admission Readmission Revenue if you need source material; Peninsula Regional is a part of this program. I think the system booted my last comment because I provided a link to source material to substantiate my claim.
Disclaimer: I'm not a lawyer and this is simply my understanding of how ARR and "Under Observations" work.
Note: The ARR agreement imposes a case mix adjusted standard bundled Admission-Readmission Charge Per Episode (ARR-CPE) target for each ARR hospital, which applies to inpatient admissions and subsequent readmissions.
7:56 And for us just common folks are you just saying "the fish jumped clean over the boat". Does HSCRC require the use of case hardened latex rockwell surgical instruments? If so, must they be bundled with a crescent wrench, vice grips, and a screwdriver? So, if I'm admitted under observation, I'll just sit there and you will just look at me? What a load of crap.
ReplyDeleteSince everything has been flipped upside down on it's head with the fiasco obamacare is, I can only tell you the way it USED to be. It may still be the same I don't know. Since the cuts to Medicare because of obamacare it may be different. Previously Medicare would have paid for a 3 day stay. Rules stated, if you stayed in the hospital over 48 hrs it was then an admission any thing less could be or was considered under observation which would most likely be picked up by your private insurer.
ReplyDelete@8:30
ReplyDeleteI'm sorry but I don't know what "the fish jumped clean over the boat" means. There are approved lists of vendors that sell qualified materials that may be used in the hospital environment but I'm not sure you're even being serious; rather, just attempting to ridicule a thoughtful explanation of what is happening.
I only tried to explain how it works; not put any personal spin on it. I don't agree with it or like it as a means of payment but it is what it is. The state is trying to control spiraling costs that providers charge to Medicare, Medicaid and private insurers. That's why ARR was born because the State puts the blame squarely on the providers for attempting to bill for as many services as they can think of during a course of stay.
Personally, I don't like any of it and think we should abolish the whole system in favor of single-payer. I don't like ACA and I don't like capitalist oriented private insurance and providers vying to squeeze consumers for every penny everytime they get a busted ankle or a twinge in their spine. Medical care should be a state service - end of story. I'm not going to get into an argument over it but the comment seemed disparaging as if I condone this sort of thing - I'm simply trying to help the OP to understand why she's being billed that way.
You common folks could become enlightened by doing some research on the internet since you obliviously have access to it.
ReplyDeleteIt happened to me in Texas a few years ago BEFORE Obamacare. Had a real problem getting it corrected.
ReplyDelete