Frequently Asked Questions
Medicare Hospital Status: What You Need to Know
Due to Medicare regulations, hospitalized patients must be assigned either outpatient status with observation services or inpatient status with an admission order. While you are at Newton-Wellesley, your admitting physician will assign you one of these two statuses depending on the reason for hospitalization and the expected length of stay.
What is the difference between inpatient and outpatient status?
Your hospital visit status is determined by the number of days you will need medically necessary hospital services. Your physician considers a number of factors to make this decision including, but not limited to, the severity of your condition and the need for monitoring and treatment in the hospital. Observation services are considered hospital outpatient services to allow for testing and medical evaluation of your condition with the expectation that your care will not exceed more than one midnight. During this time, your room may be located anywhere within the hospital. You will continue to receive the highest quality care regardless of your hospital visit status. Within the first 18-24 hours of your outpatient stay, your hospital physician will decide if you require inpatient admission or if you can be safely discharged.
What kinds of conditions usually require observation services?
Observation services are typically for conditions that can be treated in 24-48 hours. This often occurs when the cause of your symptoms has not yet been determined or you have complications after a surgical procedure. Some examples include nausea, vomiting, weakness, stomach pain, headache, kidney stones, fever, some breathing problems and some types of chest pain.
Is my financial obligation affected by my inpatient or outpatient status?
Yes. Your hospital visit status is important because it may affect the amount you pay for hospital services, deductibles, co-payments and co-insurance. If you are admitted to the hospital as an inpatient, your care and treatment is covered by Medicare Part A. If you are observed as an outpatient, the care you receive is considered by Medicare to be an outpatient service. Your Medicare Part B benefit covers outpatient and physician services, but there may be deductibles and/or co-payments associated with specific types of care provided during your stay.
Can my hospital visit status change?
Yes. Your hospital visit status may change from outpatient to inpatient (as well as vice versa.) Status changes usually occur within the first 48 hours of your stay. Your health care team will keep you informed of your status and answer any questions you may have. at Newton-Wellesley Hospital
What if my physician decides that I do not require inpatient care?
Your providers, case managers and nurses will work with you and your family to plan a safe and reasonable discharge.
What if I need monitoring after undergoing an outpatient surgical procedure?
Medicare allows for a routine post-procedure recovery period. The intent of outpatient surgery is to have your surgery and be discharged after one overnight if needed. However, if you experience a post-operative complication, your physician may either order observation services or admit you to inpatient status depending on how long you are expected to require monitoring.
Does observation care count for Medicare’s three-day hospital stay requirement for skilled nursing facility (“SNF”) care?
No. Any time spent receiving observation services will not count toward a “qualifying hospital stay” under Medicare’s rules. A qualifying hospital stay means that you need to be hospitalized as an inpatient for three consecutive overnights in an acute care facility (hospital) within the last 30 days. If your hospital visit status changes from outpatient to inpatient, your three-day hospital stay begins when your provider orders inpatient care. Please note that assistance with daily activities such as supervision to prevent falls, bathing, walking and transferring from bed to chair is not eligible for acute care hospitalization per Medicare regulation.
Rules about Medicare coverage are set by the federal government. More information is available by calling Medicare at 1-800-MEDICARE (1-800-633-4227). Also, to learn about how Medicare covers care in a SNF, visit www.medicare.gov/publications to view the booklet “Medicare Coverage of Skilled Nursing Facility Care.”
We strive to provide the highest quality care, if you have any questions about your hospital status, please ask your case manager or call 617-243-6695.
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