Hospitals provide Hospital-Issued Notices of Noncoverage (HINNs) to beneficiaries prior to admission, at admission, or at any point during an inpatient stay if the hospital determines that the care the beneficiary is receiving, or is about to receive, is not covered because it is:
– Not medically necessary;
– Not delivered in the most appropriate setting; or
– Is custodial in nature.
The patient may disagree with the finding and they have options:
Talk to your doctor about this notice and any further healthcare you may need
You also have the right to an appeal; that is an immediate review of your case by the Quality Improvement Organization (QIO). The QIO is an outside reviewer hired by Medicare to make a formal decision about whether your admission is covered by medicare.
QIO Contact Information:
LIVANTA BFCC-QIO: 1 866-815-5440 TTY 1 866 868-2289
The Care Manager often arranges home care services before the patient is discharged from the hospital. I a patient defers any home care before discharge, and then services are needed after discharge a community referral is made by the physician.
Skilled Services: provided by professional healthcare people such as Registered Nurses, Physical Therapists, Speech therapists, Occupational Therapists, and Medical Social Workers.
Custodial Care: provided by a Home Health Aide (HHA) or a Personal Care Aide (PCA). This includes:
- Bathing
- Meal Preparation
- Feeding
- Toileting
- Supervision
- Or any other care that does not require a professional
In some hospitals there are still some primary care physicians that see their patients in the hospital. The days of your primary care physician or “PCP” seeing you in the hospital is pretty much long gone. Primary care physicians are very busy in there offices seeing one patient after the next. Just like any industry and business, running a hospital is a business. Physicians need to be efficient during the admission, management and discharge process. After all, there are risks of being in a hospital too long such as acquire hospital born illnesses. Hospital Medicine has more or less become a specialized area. Doctors who work in the hospital taking care of hospital patients will typically admit the patient, manage patients and discharge patients when it is appropriate. Hospitalists work closely with the community of physicians throughout the admission and discharge process to ensure the smooth transition of care. Medical records are updated and exchanged and, if your doctor prefers, a phone call is made as well.
No, Medicare will only pay if there is a medical condition that warrants postoperative monitoring. If you desire to stay over for patient/family convenience, you will be fully responsible for payment.
It is possible. For example, Medicare allows for a 4-6 hour recovery period. The intent of outpatient surgery is to have your surgery and be discharged the same day. However, if you experience a post-operative complication, then your physician may place you into observation to monitor you further.
You will be discharged from the hospital.
Your physician must then write an order to convert your outpatient observation stay to a full inpatient admission.
Medicare – observation services cannot exceed 48 hours. Typically a decision to discharge or admit is made within 24 hours.
Medicaid allows up to 48 hours
Private Insurances may vary but most permit only 23 hours in observation.
At the end of your observation stay, your physician will decide whether to discharge you from the hospital or to admit you as an inpatient.
- Medicare Part B covers outpatient hospital services. Generally, this means you pay a co-payment for each individual outpatient hospital service. This amount may vary by service.
- Note: The co-payment for a single outpatient hospital service can’t be more than the inpatient hospital deductible. However, your total co-payment for all outpatient services may be more than the inpatient hospital deductible.
- Part B also covers most of your doctor services when you’re a hospital outpatient. You pay 20% of the medicare-approved amount after you pay the Part B deductible.
- Generally, the prescription and over-the-counter drugs you get in an outpatient setting (like an emergency department), sometimes called “self-administered drugs,” aren’t covered by Part B. Also, for safety reasons, many hospitals have policies that don’t allow patients to bring prescription or other drugs from home. You you have Medicare prescription drug coverage (Part D), these drugs may be covered under certain circumstances. You likely will need to pay out-of-pocket for these drugs and submit a claim to your drug plan for a refund. Call your plan for more info.
- Medicare Part A (Hospital Insurance) covers inpatient hospital services. In general this means you pay a one-time deductible for all of your hospital services for the first 60 days you’r in the hospital.
- Medicare Part B (Medical Insurance) covers most of your doctor services when you’re an inpatient. You pay 20% of the medicare-approved amount for doctor services after paying the part B deductible.
If you’re in the hospital more than a few hours, always ask your doctor or the hospital staff if you’re an inpatient or an outpatient.
You’re an outpatient if you’re getting emergency department services, observation services, outpatient surgery, lab tests, or x-rays, and the doctor hasn’t written an order ot admit you to the hospital as an inpatient. In these cases you’re an outpatient even if you spend the night at the hospital.
You’re an inpatient starting the day you’re formally admitted to the hospital with a doctor’s order. The day before you’re discharged is your last inpatient day.
The decision for inpatient hospital admission is a complex medical decision based on your doctor’s judgment and your need for medically necessary hospital care. An inpatient admission is generally appropriate when you’re expected to need 2 or more midnights of medically necessary hospital care, but your doctor must order such admission and the hospital must formally admit you in order for you to become an inpatient.
There are several reasons why many hospitalist programs in the United States began to use a dedicated admitter. Hospitalists rounding on 15-20 patients per day on the floors meet with families, case managers and social workers throughout the day. We want Hospitalists to focus on their patients and not be taken away from discharging and caring for sick patients to admit new patients. Many clinicians claim that it not only improves hospitalist satisfaction by giving hospitalists time to focus on either admitting or rounding, but improves a hospital’s throughput and potentially reduces length of stay. The thought is that having a dedicated admitter in the Emergency Department allows the admitter to see patients quicker, admit the patients and get patients moving without bottlenecks. However, bottlenecks do occur quit and patient satisfaction can as well especially when the admitologist is hit with 3-4 admissions at one time and they must focus on the sickest first and often this causes a delay in admission. Some Groups have found that having an admitter in the ED reduces ER length of stay. This is all relative and is affected by a number of factors in the hospital.
A type of Hospitalist. A Physician, Usually trained in Internal Medicine who admits patients to the Hospital. Admitologist are special in that they have a strong understanding of the overall healthcare system and how it functions. Admitologists typically work closely with ER physicians, case managers and social workers in a collaborative way in assessing, planning, implementing, coordinating and evaluating the options for patients and their disposition in acute care hospitals. Admitologists are proficient and efficient in the admitting processes.
The Society of Hospital Medicine has adopted the following official definition of “hospitalist.”
Hospitalists are physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.
The term “hospitalist” refers to physicians whose practice emphasizes providing care for hospitalized patients. The term was first used in a New England Journal of Medicine article in August of 1996. While some doctors have emphasized inpatient care for many years, there has been an explosive growth in the number of such doctors since 1994.
Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med 1996;335:514-7.
