Geriatric Care Managers Can Help Families Understand Medicare Complexities and Reduce Hospitalization Costs

Medicare Claim Denied

Medicare Trap: Hospital Outpatient Classification

If you — or a loved one — are Medicare-eligible and find it necessary to visit a hospital emergency room for a medical emergency, you might assume that Medicare will cover most — if not all — of the costs of your emergency hospital care and treatment. But more and more often this is not the case — and more and more senior citizens are discovering that they are responsible for paying thousands of dollars in unanticipated medical costs they assumed would be paid for by Medicare.

Here’s what’s happening and how a geriatric care manager can help:

Hospitals are increasingly classifying senior citizen hospital visits as outpatient visits instead of inpatient visits — even when the patient is placed in a bed in the hospital, stays overnight and receives medically necessary care.

Debbi Borgstrom, Clinical Supervisor for Cleansing Water, Inc., says: “At the time any person is entering an emergency room at the hospital, the family is in crisis. The hospital may explain that the person will be in an “observational bed” in order to watch the person for a few hours, but they may not take the time to explain what that means financially for the family. A family in crisis may not be able to process the explanation. They simply want the doctors and nurses to resolve the medical crisis.”

What many patients don’t realize until after the fact — when it is too late to correct the situation — is that when the hospital classifies a patient as being “under observation” that automatically classifies them as being an “outpatient” — and that classification will make their hospital stay ineligible for Medicare reimbursement. When this happens, the patient becomes responsible for paying for a hospital stay that the patient assumed would be covered by Medicare. Medicare only reimburses expenses for inpatient hospital visits, not outpatient visits.

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On Medicare Coverage for Hospital Stays

Professional geriatric care managers are aware of this issue and know what to do to protect their clients from being stuck with unwarranted hospital charges. A professional geriatric care manager will know whom to contact within the hospital to ensure that patient hospital visits are correctly classified to qualify for Medicare reimbursement.

National Association of Professional Care Managers is Working to Change the Law

The National Association of Professional Geriatric Care Managers (NAPGCM) is calling attention to this problem and advocating legislation that will put an end to this practice.

“Seniors are being unfairly charged thousands of dollars and denied needed rehabilitation services,” says Jullie Gray, NAPGCM President. “Care managers are having some success in helping seniors avoid this Medicare trap, but the law needs to be changed,”

According to an NAPGCM survey of 315 geriatric care managers from around the nation, more than 80% of the geriatric care managers surveyed said that inappropriate hospital observation status determinations by Medicare are a significant problem facing seniors in their community. The care managers surveyed also reported that failure to receive needed rehabilitation or other services is a major problem stemming from unfair observation status rulings, and that the rulings lead to financial hardship on seniors and their families.

70% of the geriatric care managers responding to the NAPGCM survey said that contacting a hospital physician was the most helpful action step that can be taken to resolve problems associated with inappropriately being classified as in “observation status”.

According to a recent NAPGCM press release, “Seniors Increasingly Victims of Medicare”, the problem has captured the attention of some in Congress.

At a meeting earlier this month in Binghamton, New York on the topic, U.S. Senator Charles Schumer highlighted the case of Mary Opie, whose mother Mrs. Marie O’Malley was admitted last year to a local hospital after a fall which left her with arm and shoulder injuries. Because she was admitted under “observation status,” Medicare won’t cover over $7,000 in bills for long-term rehab and now she and her family have to foot the bill. It was eventually found she had torn, ruptured and severed several tendons.

Congress has introduced legislation to fix the problem, and it is gaining bipartisan support in both the House and the Senate. The “Improving Access to Medicare Coverage Act” ( H.R. 1179/S.569) would allow “observation stays” to be counted toward the three day mandatory inpatient hospital stay for Medicare coverage of skilled nursing facility services. The NAPGCM is supporting this legislation and working to ensure its passage.

About Professional Geriatric Care Management

Professional geriatric care managers (PGCMs) can bring families peace of mind and help them obtain the best health care for their loved ones. Professional care managers can:

  • advise you and your family on how to obtain the most appropriate level of health care;
  • recommend ways to contain the costs of health care;
  • help families navigate confusing hospital and health care systems;
  • recommend free or low-cost health care products and services that may be available in your local community;
  • review your insurance coverage to ensure that you are receiving the maximum benefits to which you are entitled and ensure that you are not paying bills that should be covered by your insurance.

About Cleansing Water, Inc.

Cleansing Water, Inc. is a Warrenton, Virginia home health care agency offering professional geriatric care and serving seniors, individuals recovering from surgery, individuals with long-term disabilities, and other clients throughout Fauquier, Culpeper, Gainesville, Haymarket, Middleburg, Prince William, Rappahannock and other Piedmont Virginia communities. We provide in-home companions, certified nursing assistants, and geriatric care managers to assist with the tasks of daily living, monitor health and medications, and ensure clients are well cared for, physically, mentally, emotionally and spiritually.

For more information about Cleansing Water’s short-term and long-term home health care services, Call (540) 341-0212 or our toll-free number, (866) 294-4665, to schedule a consultation and discuss your geriatric care and home health care options. You can also visit visit for more information.

Sources Cited

Seniors Increasingly Victims of Medicare

National Association of Professional Geriatric Care Managers (NAPGCM)

Centers for Medicare and Medicaid Services: Are You a Hospital Inpatient or Outpatient? If You Have Medicare: Ask!