When being admitted to hospital, no matter the reason, you will be confronted with a bewildering array of paperwork. You may be unaware that 'admitted' includes two categories -- 'inpatient' and 'outpatient.' If you have Medicare Part A, Part B and Part D insurance policies YOU SHOULD ASK - "Am I an inpatient or outpatient?"
You do not have a choice, because Medicare sets the criteria. However, you should know because being an outpatient could be costly to you. Medicare rules define medications for which you have a prescription from your doctor as "Prescriptions (Self-Administered Drugs)." As an outpatient you are responsible for payment when a "self-administered" drug is given to you from the hospital pharmacy.
"Their cost can be extremely prohibitive, and in many cases Medicare members discover an outpatient is responsible for the hospital fees for those prescription drugs too late," Rod Haynes, Centers for Medicare Medicaid Services (CMS)/ Consortium for Medicare Health Plans Operations (CMHPO) Region 10, said.This government publication explains how it works.
You need to be very clear about which prescription drugs your Medicare-D insurer covers, and the conditions under which they pay, or in some instances, DO NOT PAY. This is vital knowledge before allowing the hospital to remove any self-administered drugs you've brought with you. Medicare rules stipulate,
"If you bring your prescription(s) from home, we [the hospital] are required to obtain approval from your physician prior to use. In addition, a hospital pharmacist must verify and certify the medication before it can be used in the hospital. There is a small fee for the medication verification."
There is no standing Medicare rule mandating that hospitals must allow patients to bring in their prescriptions when receiving care. Individual hospitals may or may not choose to permit this practice.
Sean E. Dobbin, PharmD, Director of Pharmacy, Providence Sacred Heart Medical Center & Children's Hospital, explained that hospitals use digital-coding systems, much like the bar codes on items sold in stores. Hospital digital-codes coordinate your every medical procedure, including the medications you're given.
- Have been stored properly?
- Aren't from an expired batch?
- Are the strength the doctor prescribed?
- Or that dosage changes haven't been made since the prescription was written?
If for any reason you haven't reached an agreement with the hospital pharmacy beforehand, as soon as you receive their bill for the self-administered drugs you were given as an Outpatient, promptly talk to the hospital's Financial Counselor and to the Director of Pharmacy. Explain circumstances you feel should be considered, and request an adjustment. There are 'conditions' the hospital can apply to mitigate the charges.
If you need to file a claim for reimbursement from your Medicare D insurer, obtained the Prescription Drug Claim Form from the hospital's Outpatient Pharmacy Billing Department. The hospital pharmacist needs to fill out a form for each self-administered drug the hospital has billed for. Send your claim for reimbursement from your Medicare-D insurer before that insurer's deadline; keep copies.
If your claim is denied, attach copies from your original claim and file an appeal. If a medication is not covered under your Medicare-D policy present the facts to the hospital's Director of Pharmacy and requested a review by that department. The charges may be mitigated and dismissed because of 'conditions' that meet certain criteria at that hospital.