Always Ask Before Being Admitted to a Hospital ~ Am I An Outpatient? Or Am I An Inpatient?

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.

 

Why will prescription drugs you've brought (whether you're a patient in the ER or in a hospital bed) be sent home, leaving you to take medications from the hospital pharmacy instead? In most hospitals today there is no procedure whereby you can be charged a small fee and allowed to save substantial sums; the difference between what you will be charged for the hospital pharmacy's medications and your brought-from-home prescriptions. Even though they are identical.

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.

When a nurse scans the band attached to your wrist, it must match the digital-code on the medication being given. Although hospital administrators are concerned about the resulting high cost to patients, hospitals have not yet designed an efficient method to enter prescription drugs brought to the hospital by patients into their digital-coding system.
 

Complexities preventing this include: How can a hospital pharmacist ascertain the patient brought prescriptions that,

• 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?

Hospital pharmacy fees for one dose can equal or exceed the price of a thirty-day supply of the identical medication sold at your pharmacy -- a substantial difference for which your Medicare-D insurer may not reimburse you.

Many diseases require medications that are catastrophically costly, yet vital to the patient. To miss even one dose may be highly risky or even deadly, but it's up to each hospital whether or not to accept the risk/liability of a patient bringing their prescriptions from home. Before relinquishing your medications, insist on meeting with the hospital pharmacist prior to taking any medication. This way, rules can be agreed on in advance regarding your self-administered drugs, or any drugs you know your Medicare-D has restrictions for.
 

The Medicare Rules also stipulate, "As a courtesy, we will bill your supplemental insurance on an "assignment" basis. This means we will ask the insurance company to pay us directly. Any amount not covered by your insurance will be your responsibility."
 

This does not apply to medications in the self-administered category. According to a finanial counselor at Providence Sacred Heart Medical Center and Children's Hospital, Spokane, WA, it means the hospital may bill for covered medications under Medicare Part A Supplement Plan. Hospitals do not bill insurance companies for self-administered prescription drugs received from the hospital pharmacy that are covered by Medicare-D insurance. The patient is billed and bears the responsibility to file a claim for reimbursement from their insurer.
 

Haynes said Part D is a separate matter entirely. "While hospital pharmacies are technically permitted to contract with Part D plan, it is very rare for them to do so because of financial constraints. If a hospital is willing to submit a patient's Outpatient drug claims to his or her Part D plan for reimbursement prior to billing the patient directly, such an arrangement would be entirely up to the hospital pharmacy. There is no Medicare rule mandating that the hospital do this," he said. The patient is left to suffer the consequences – or seek relief.

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.

If your insurance doesn't cover the costs, and you fail to get remediation from the hospital pharmacy, meet with the hospital's Financial Counselor. You may qualify for financial assistance, or at least be able to arrange an acceptable payment plan.

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Sources:

Medicare.gov, the Official U.S. Government site for Medicare.

Search self administered drugs to get a the (pdf) Publication, "Self Administered Drugs" It explains how Medicare covers self-administered drugs given in hospital outpatient settings.
Here you can find 118 Publications that answer Medicare questions.
 

Give Yourself The Best Chance to Survive a Heart Attack or Stroke

Know how to give yourself the best chance to survive a heart attack or stroke. Learn to recognize symptoms, and take fast action!!

When the heart goes out of rhythm enough to cause a heart attack (your pulse feels irregular, too fast, too slow, or pounding) then it MUST be brought back into rhythm. You also need oxygen because your heart isn't pumping well enough to meet your body's need for blood-carrying-oxygen, especially to your brain. A doctor may prescribe medication, or you may need defibrillation.

You may not think clearly.

A quick assessment for stroke:
S -- Smile. If lopsided, call 9-1-1.
T -- Talk. Any difficulty with speech, call 9-1-1.
R -- Raise arms -- if unevenly raised,  9-1-1.

Call 9-1-1 immediately if you suspect a heart attack or stroke. It's better to be embarrassed than dead, or risk having your lifestyle diminished because you delayed.

If you are driving a car, the best thing to do is stop at the very first place where a phone can be found -- a house, a store, some motorist with a cell phone, wherever -- and call 9-1-1.

If you're 5 miles or LESS from the nearest hospital stopping by the roadside and flagging someone to drive you there could be a better option, because of the time it takes for an ambulance to reach you.

However, ambulances and fire department Quick Response units carry oxygen, which vastly improves your chances. So if you know an ambulance or fire station is close, that's your best choice.
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Don't Risk Premature Hospital Discharge: Appeal

You've been in the hospital for three midnights, or more, as an Inpatient not an Outpatient, but you don't agree when your doctor says you're ready for discharge. It just doesn't 'feel right.' You're afraid. You don't want to land back in the hospital for the same ailment. You'd like a second opinion.

 

What can you do other than stay ~ and pay?

 

If you're an original Medicare beneficiary, appeal your discharge. Details and instructions are on the Important Message from Medicare (IM), given to you by the hospital when you arrived. You signed it, along with a batch of other admittance documents.

 

Lost the IM? Ask for a copy.*

 

If you suspect premature discharge, as soon as you learn of your impending discharge act quickly.

 

Protect yourself from a potential premature discharge by calling the Quality Improvement Organization (QIO) number on the IM.*

 

Called 'fast' or 'expedited' appeal, your phone call will start the process of a review made by a QIO. An 'expedited' appeal gets you a second opinion and buys time, without cost to you.

 

A QIO is under contract with the government: your medical records are examined by a physician, independent of the hospital, to review the medical necessity, appropriateness, and the quality of hospital treatment. The appeal is completed quickly and renders a final decision. The appeal also lets you stay in the hospital until noon (at least) of the day following your discharge date, and Medicare benefits apply during the time of the appeal process.***

 

You start the process by phoning QIO, and it should be completed in no longer than seventy-two hours, but you must call QIO before midnight on your discharge orders date.

• Upon receiving an appeal request from the beneficiary, the QIO must notify the hospital immediately of the review request.
• The hospital must provide patient records to the QIO by noon on the day after the QIO initially alerts the hospital to the expedited review request.

Note - there are reasons QIO may not alert the hospital for a considerable length of time, and also reasons why the hospital transmittal of records may not be complete for a considerable length of time - as long as seventy-two hour delays are possible.

 

Once the QIO notifies the hospital, the hospital is required to give a Detailed Notice of Discharge to the beneficiary (you) and to the QIO by noon the day after it is first notified of the appeal.

 

The Detailed Notice states the hospitals detailed rationale for the discharge. The QIO must receive a copy of the Detailed Notice in order to make a determination. The Detailed Notice also includes hospital contact information for the beneficiary.****

 

If you do not receive the Detailed Notice by noon the day after you contact the QIO with an appeal request, act quickly. Report this to the QIO so that the QIO can take action to facilitate delivery of the notice to you. You'll know your appeal is going as scheduled when you receive it.

 

The QIO must make its determination and notify the beneficiary, hospital, and physician within one calendar day of receipt of all pertinent information (delays can occur until records are complete.)

 

The hospital is prohibited from discharging you during your appeal, however if you leave the hospital before the review is complete, you abort your appeal.

 

If the QIO agrees that discharge is appropriate, you can agree to the discharge or you can file a reconsideration request for an independent review entity to review the case. If you stay in the hospital following receipt of a QIO decision that the doctor’s discharge orders are appropriate, you should receive a HINN12 from the hospital, because unlike the initial expedited review, there are no financial protections during the reconsideration process.

 

Sidebar:

• *Medicare, Medicare Advantage, and Medicaid each provide a hospital discharge appeals process.
• http://www.cms.hhs.gov/.
• ** If the beneficiary wishes to appoint a representative to file an appeal on his/her behalf, a valid Form 1696 or a conforming written instrument must be signed by both the beneficiary and the prospective representative and filed with the appeal request. In such cases the hospital has very specific obligations regarding notifications to the representative.)
• ***Medicare does not cover inpatient hospital services that are not medically necessary or could be safely furnished in another setting. (Refer to 42 Code of Federal Regulations, 411.15 (g) and (k)). Options also remain to appeal an adverse decision.
• ****Detailed Notice, Form CMS-10066, http://www.cms.hhs.gov/BNI/Downloads/Detailed_Notice_English_and_Spanish.zip.

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