Frequently Asked Questions
Who determines whether my admission is considered observation or inpatient?
The physician responsible for your care while you are in the Hospital decides whether your illness and treatment will require an observation or inpatient admission.
He or she makes this decision to be in compliance with governmental and/or commercial insurance regulations by:
- Working closely with case managers who use an objective set of published criteria to assist in the determination.
- Collaborating with an independent physician advisor who has knowledge and expertise in interpreting governmental (Medicare) regulations.
Why would the admitting physician admit me to an “observation” status?
Insurance companies including Medicare have guidelines to assist in determining an observation or inpatient designation. The admitting physician often places patients in an observation status for the following reasons:
- If it is not clear that an inpatient admission is required and additional time is needed to evaluate your symptoms or situation.
- If the admitting physician believes that your illness can be diagnosed and appropriately treated with an anticipated discharge within 24-48 hours.
How will the type of admission I have affect:
The medical oversight and treatment you receive will be the same regardless of your type of admission.
My Out-of-Pocket Expenses:
There are financial implications to your admission status.
- If you are admitted to the Hospital as an inpatient, your care and treatment is covered under your Medicare Part A benefit.
- If you are admitted in observation, the care you receive is considered by Medicare to be an outpatient service. While your Medicare Part B benefit covers outpatient and physician services, there may be a deductible and/or co-payment associated with specific types of care provided during your admission.
- There may be a co-payment associated with specific types of care provided during your admission. It is important for you to know your coverage benefits.
My Discharge Plan:
Discharge planning services are available to you regardless of your type of insurance and whether you are designated as observation or admitted as inpatient. Recommendations for discharge are based on input from all disciplines involved in your care including the physician treating you during your hospitalization, the nursing staff and rehabilitation therapists.
Medicare subscribers with the exception of Medicare Advantage subscribers:
- An observation/inpatient designation affects whether Medicare will cover payment for a skilled nursing facility.
Below is a brief description of the standard Medicare benefit:
- Medicare will cover the care you receive at a skilled nursing facility (SNF) only if you have a “qualifying hospital stay”. This means that you need to have been hospitalized as an inpatient for three consecutive overnights in an acute care facility (hospital) within the last 30 days.
- An observation admission is viewed by Medicare as outpatient treatment; therefore, the time you are hospitalized as an observation patient does not count towards the required three-day stay.
- Helping you with activities of daily living such as supervision to prevent falls, bathing, walking and transferring from bed to chair does not require a continued acute care hospitalization under your Medicare benefit.
For Commercial and Medicare Advantage subscribers:
- Insurer approval rather than inpatient/observation designation will determine approval for coverage to a skilled nursing facility.
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