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9-1-1 Buddy & Tip Sheet

Most Accidental Safari’s begin suddenly, with an unwelcomed surprise such as a fall, stroke, or heart attack. Are you prepared for the sequence of events that usually follows that first 911 call?

If you are the one who has just entered the Safari, you need an advocate! An advocate is someone who will be in your corner and at your side, from the moment the gurney is forced through the emergency room doors. Your sudden arrival kicks into motion a series of events that can mean the difference between life or death, recovery or remaining in a care facility. Some of these decisions will save or cost you thousands of dollars.

Once you are inside the emergency room, the physician will order tests that he or she thinks is necessary to determine or confirm your condition. If the tests indicate a serious problem, you will be admitted to the hospital as a “patient” for treatment. If the test results are negative, you will be sent home.

But what happens when the test results are inconclusive? The test results may suggest that there could be an underlying, undiagnosed issue. If the hospital has sent you home and you collapse soon afterward from that “unknown something connected to the test that showed a little something was going on”, the hospital could be liable for not taking additional measures to avert your ensuing ride through town under sirens and flashing lights.

Test results with “gray areas” present a serious quandary for hospitals, which must maintain a balance between compassionate care and financial stability. In order to admit you as a “patient,” they must be able to check enough of the required boxes on the Admittance Form to satisfy Medicare’s admission requirements. Medicare controls how much the hospital gets paid for the services it provides and the sad reality is that hospitals must consider that Medicare might not pay and, even worse, that a Medicare audit could suggest that the hospital is guilty of Medicare fraud.

Faced with this conundrum, the safest option for the hospital is to place you in a hospital room, “under observation”. Sadly, this will NOT be the best option for you! Whether you are admitted as a “patient” or placed in a room “under observation” will determine who will pay for your future treatment. If you are admitted to the hospital as a “patient” for three full days, and are subsequently moved to a rehabilitation facility, Medicare will pay all the costs of the first 20 days of rehab, where costs can easily exceed $500 per day. Medicare will also pay all but the first approximately $170 per day for the following 80 days in rehab. Also, most Medicare supplemental health insurance plans will cover the first approximate $170 per day if Medicare is paying the back end.

Being in the hospital “under observation”, but not a “patient” of the hospital, will not qualify you for Medicare to pay for your future rehabilitation period. This is where your advocate should step in to protect you. The advocate should confirm your status in the hospital from day one: “patient” or “under observation”? If you are “under observation”, the advocate needs to immediately ask two important questions: 1) Why aren’t you a “patient” and 2) What can be done to allow the hospital to check enough boxes on the Medicare form to admit you as a patient. The hospital knows how the system works and although they would like to admit you as a patient, you must meet the Medicare requirements. By asking the medical team what is missing from the form, your advocate may be able to provide the additional information necessary to qualify you as a “patient”.

Advocacy is an essential part of your life care plan. Do you know who your best advocate is or will be? More importantly, does your advocate know that you are expecting them to step up on your behalf? Does he or she know what the issues are that you are expecting them to address?

An Accidental Safari often begins in the Emergency Room, and the dangers there are as perilous as those in a jungle. Let’s take the steps to prepare to meet whatever challenges may come around the next turn in the road.

Article Written By:

Richard C. Tizzano, Elder Law & Estate Planning Attorney

Sherrard McGonagle Tizzano & Lind

19717 Front Street, Poulsbo


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