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The Difference between Admitted and Observation

Admitted vs. Observation in the Hospital

When your parent is in the hospital for any reason, it is stressful and worrying. It doesn’t make it any easier when you are also unsure of how their hospital stay affects their out-of-pocket medical costs, what is covered by Medicare, and how to navigate the systems that can explain all that. But you can get peace of mind by understanding some of the terminology. Perhaps most important is understanding the difference between ‘observation’ and ‘admitted’.

One way to get support in this discovery process is to call Oasis Senior Advisors to speak to someone who can explain some of the fundamentals. Don’t hesitate to reach out for a free consultation. Use our online form or dial 475.619.4123 or 914.356.1901 today

Hospital Status—Admitted or Under Observation?

Because it makes a difference if your parent is admitted or only under observation, hospitals are required to let you know what the status is, and they usually do. Sometimes, though, information can fall between the cracks, or you may not really understand what the status means about your parent’s insurance. This is the worst time to be under additional stress from financial worry or confusion.

For example, did you know that if your mom or dad is under observation—meaning not formally admitted to the hospital—for more than 24 hours, there is a potential that big copays may accrue? Medicare payments for post-discharge nursing home rehab stays are also affected by the status of the prior hospital stay status.

As the terms imply, “admitted” means the patient is in the hospital under the care of a doctor, and “under observation” means the patient is staying in the hospital but as an outpatient. Even though they spend the night, no admissions papers have been signed making them an admitted inpatient in the hospital.  In effect, they are in the Emergency Room even if they may not be in the ER itself.

Procedures can be done while under observation, so the fact that your parent receives an MRI or a biopsy does not confirm anything one way or the other about admissions status.

Relationship between Admissions Status and Medicare Coverage

Both the time spent in the hospital and any post-hospital care are covered by Medicare at higher amounts if the patient is admitted. Any time in the emergency department prior to admission and the day of discharge is considered outpatient and is billed at a higher rate.

Out-of-pocket charges are significantly higher when your parent is under observation or awaiting admission.

Rehab in a Skilled Nursing Facility—Is It Covered?

The answer to this question is sometimes yes, sometimes no, otherwise known as: it depends.

Medicare will cover post-discharge skilled rehab if your parent has a “qualifying hospital stay,” which means he or she:

  • Was admitted to the hospital as an inpatient
  • Was in the hospital for three days or more with that inpatient status

If your parent:

  • Was in the hospital for more than three days but was admitted as an inpatient for fewer than three days
  • Had the status of “under observation” for the entire time or enough that there were not three days of admitted status

…there is no qualifying hospital stay, and skilled nursing care will not be covered.

This is not something you want to be surprised with only after the bills come. It’s something you want to be aware of at the moment and advocate for if a post-discharge rehab stay seems likely or needed.

Find Out More with Oasis Senior Advisors

It’s important to understand Medicare coverage of hospital stays, each related service during your loved one’s stay, and post-hospital skilled nursing care. Depending on inpatient or observation status, your parent may have to pay deductibles or a copay for each service. Medication coverage may be affected too. Knowing the facts ahead of time can save your loved one money and both of you a lot of undue stress. You do not have to figure all of this out by yourself. Hospitals often have staff who help people just like you understand the billing, the terminology, and expectations. Seek out the business department and the social worker for clarification. You can also have Oasis Senior Advisors help you. We can demystify these two different but related kinds of hospital stay and how that difference can affect your bottom line. Reach out by using our online form or just give us a call at 475.619.4123 or 914.356.1901.

Oasis Senior Advisors

Fairfield-Westchester

are here to help

Paul and Susan Doyle

Certified Senior Advisor®

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475-619-4123