Sunrise, Sunset

I have wanted to sit down and write to you for the longest time! I wasn’t able to, in large part, because my 93 year-old Mom took a terrible fall at the beginning of January and was in the hospital for several days, and then in a skilled nursing facility, and back into the hospital several times after that. My sister, Carol, who lives in Mom’s town of Roseburg, Oregon, was there with her.

It wasn’t Mom’s recovery that was gobbling up my time but rather the terrible financial, legal, insurance mess we’ve been slogging through ever since her fall. I can’t begin to tell you how many times round and round the complex issues of health care for the elderly Carol and I have gone, but I can tell you it was deeply distressing. However, experiencing what we have has been a painful education.

And what we learned is so important I need to tell you all about it, even though it certainly won’t be as interesting as the continuing story of D. H. Lawrence and Mable Dodge Luhan (that’s coming soon-ish I promise). But I think it’s critical that each and every one of us be informed about this, with the purpose of ultimately making clear, educated choices for ourselves or our loved ones in the event of a medical emergency.

You probably think (if you think about it at all) that when you or your parents are on Medicare, along with a supplemental insurance, that you’re fully protected, right? But that’s not always true. In fact often it’s not.

You see Medicare has created a kind of self-supporting legal quagmire that, whether it is meant to or not, denies its beneficiaries the ability to use their insurance in certain important instances. In this way, Medicare claims are not only being denied, but often they aren’t even being filed because, under its own rules, they do not qualify.

I want to believe this is an accident, but the suspicious part of me fears it is not. I’m afraid Medicare is purposely excluding thousands of seniors from using their own insurance, not by accident, but by design.

It all hangs on three important designations. They are inpatient, outpatient and observation status.

Let me tell you what happened to my mom in an effort to untangle this a bit so that it will make some sense and you can tell me what you think.

Mom, a 93 year-old Medicare senior, fell on the ice when she went out to get the mail, breaking her hip, her pelvis and her wrist. She lay there on the ground for awhile before anyone saw her, and I just hate thinking about that. But she was finally rushed to the ER at her local Roseburg hospital, Mercy Medical Center, where she was diagnosed, her wrist was set and splinted and she was told to go home.

First off let me say that, although my mom spent every stage of her life as a tough nut who’d come through poverty and the depression and who never whined, she was traumatized by this whole experience. Here she was sitting in the ER, STILL chilled through, in pain and, frankly, scared. She couldn’t stand, let alone walk. She was going in and out of AFib, and the hospital, the same one she’d believed in ever since moving to Roseburg in the late 1970s, was telling her to go home.

After much wrangling and some actual tears being shed, my sister got the hospital to acquiesce. They agreed to admit Mom under observation status. We were greatly relieved to say the least.

But contrary to what most of us believe, just because you’re admitted to the hospital, doesn’t mean you’re necessarily an inpatient. Even when you’re checked into an actual hospital room and bed for many days, receiving the same level of care as inpatients, you may well have been admitted to the hospital as an outpatient. As was my mom.

But why should we care? What difference does it make to us?

A huge one as it turns out. Medicare won’t pay for a skilled nursing facility unless you’ve been an inpatient in the hospital for at least three midnights. Mom wasn’t.

And, you guessed it, she couldn’t go directly home (as is true for most seniors after a serious injury), so she was discharged to a skilled nursing facility where she received the daily physical and occupational therapy she needed. My poor mom had to learn to stand and walk again with all that pain from her fractured hip and pelvis. She even had to be taught everyday things like how to brush her teeth or her hair, to put in her contacts, to hold a phone, while healing that broken wrist. That kind of care is expensive. And I think that’s why Medicare has gone to such lengths to get out of paying for it.

Many attribute hospitals’ increased use of outpatient versus inpatient coding to a program created by Congress to audit providers’ (hospitals in my mom’s case) Medicare claims with an eye to identifying over payments or fraud (meaning that Medicare has paid for services the auditor feels they shouldn’t have), an important program obviously. We all know about excessive Medicare fraud.

But these auditors receive a commission for every over payment they think they’ve found and are never penalized if they are mistaken. “As a result,” says an American Hospitals Association survey report, “[The auditors] have focused the majority of their audits on inpatient hospital claims…”  because those pay the highest dividends and are also the greatest source of Medicare fraud.

So if you’re a hospital, this would be a little like having the constant threat of an IRS audit hanging over you. And this “IRS” is most likely to scrutinize inpatients with the power to overthrow any of your billing decisions. Wouldn’t it be very tempting to admit more patients as outpatients and save yourself a ton of money and time? Indeed it would be. And so they do.

And my mom fell smack in the middle of all of this.

It seems I spent months, and in fact I did spend almost two, calling various people at the hospital, at Medicare, the skilled nursing facility and Mom’s secondary insurance agent piecing this all together. I knew I had to be misunderstanding something and that Mom’s Medicare would certainly cover the cost of her care. But I was wrong.

I went round and round in endless circles calling one lead after another, but no one wanted to admit that this loophole existed. Yet they knew all along (except for Mom’s nice insurance agent. I think she was genuinely in the dark about it). And it still lies unresolved for us.

Although I do want to mention that Oregon’s 4th District Congressman, Peter DeFazio’s, Medicare Specialist has taken all of our information and we’re hopeful his office will be able to do something (the Congressman had already signed onto the legislation I reference below). I’m very grateful that someone in a position of power is listening. Thank you Congressman and Vanessa. You are a calm port in the storm.

There are several things you can do. First, there is bipartisan support (a miracle these days) in Congress to fix this problem. It is the Improving Access to Medicare Coverage Act of 2015 (H.R. 1571 and S. 843). This legislation would require that time spent in observation be counted toward meeting the three-day prior inpatient stay that is necessary to qualify for coverage of a skilled nursing facility under Medicare.

If every one of us would take a few minutes to contact our federal representation and ask them to cosponsor this legislation, we could make a difference. I think it’s worth a shot.

And there are also things you can do if you find yourselves or your loved ones faced with this very wrong situation. I urge you to go to medicareadvocacy.org and familiarize yourselves with your rights and the steps you can take to protect yourselves and those you love.

Mom was originally in the hospital for four nights. While there she had been found to have some abnormal heart function beyond AFib and was still unable to walk when she was discharged to a skilled nursing facility.

Our story has ended terribly. My dear mom passed away this morning still very worried about the more than $30,000 tab she’d incurred at the skilled nursing facility.

But one week ago, on her last day of lucidity, my sister and I and all of Mom’s grandchildren and great-grandchildren, her whole family, gathered at her bedside to say goodbye.

Bless you beloved Mother. Rest in peace.

Love to you all,

Jeane