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Medicare story

Forherself's picture
Forherself
Posts: 595
Joined: Jan 2019

I want to share this slightly off topic story because many of us have Medicare.  I recently had spinal fusion surgery and stayed one night.  I am an RN and can manage my care at home, and I am concerned about the risk of hospital borne infection, especially MRSA and COVID.  I have Medicare and Regence Blue Shield supplemental.  After reading other Medicare stories here, I bought the most inclusive insurance I could.  After recovering 3 weeks at home, I received a letter from the Hospital saying they decided not to bill Medicare, as I was an outpatient, and I was liable for the cost of my hospital stay.   The hospital sent it by registered letter so I had to go to the Post Office to get the letter.  It was so scary to receive this, and they were implying that since I only stayed one night they were not going to bill Medicare.  They said generally patients had to stay two nights for Medicare to cover the stay.   I didn't know if I would be liable for the whole surgery or not!   It was very scary, and also felt intimidating and almost bully like.  I have never taken kindly to bullies so I sent a letter suggesting their panel review my case and go ahead and bill Medicare.  I felt this was an arbitrary decision.   I was scared at first and then angry.  I have read articles about people with insurance problems contacting politicians so I contacted one of our County Council Members.   Within half an hour she answered me saying she wanted to escalate this issue with the hospital.   She immediately wrote to the CEO of the hospital.   I had also sent a copy of the hospital letter to my surgeon with a copy of my reply.  I told the hospital that I would go on social media and share the letter and I would do everything I could to change this process of intimidating patients after they leave the hospital.   Well, today I heard from the hospital.  My "case manager" said she looked at my insurance and I had good medicare and coverage for outpatients services so the only charge I would have was the deductible of $273.00.   I told her thank you and how little I thought of the intimidating tactics she used with her letter.   

I am writing this because others may find themselves in the position I did.  Know that there is help out there, and it is not a decision that is written in stone.  Do not be afraid to write to the hospital.  I sent my letter by registered mail also.  And remember politicians, local politicians can help.  I am going on a campaign to shine light on this dark practice, and help people deal with this.

alicia2020
Posts: 164
Joined: Sep 2020

I'm so sorry you had to go through all that! That is so wrong of the hospital to do that to you! Bravo for you making a fuss and advocating for yourself! Good idea to think of getting politicians involved. It's sad to think of a hospital just arbitrarily making that decision and sending out such letter a letter. And what I kind of don't understand is that the hospital I've used makes a big production of it every time I step into their doors, making sure all my insurance information is current....the whole point being that they are assured they will be paid. I think if the hospital was doing their job they should have informed you ahead of time that if you stayed overnight they might bill you. I'm glad you spoke up & were able to fix it!

I have Medicare and AARP supplemental Plan G. I had to spend one night after my second surgery, but I never got a bill. I was a new Medicare person as of June last summer & then all my problems started in July. I know how scary it can be. For the first several months into my treatment every time my husband said, "I'm going to get the mail," I held my breath praying there wouldn't be some big, unexpected bill. Thank goodness one never came!

Thanks for sharing!

Alicia

NoTimeForCancer's picture
NoTimeForCancer
Posts: 2937
Joined: Mar 2013

Forherself, good for you for fighting back!  It is infuritating to have been treated that way and that THEY would decide not to even try billing Medicare. It is tough enough to be your own advocate for treatment but to have to also manage them on the billing is ridiculous since they have plenty of paper pushers.  Unfortunately we always have to watch the bills!  My uncle was receiving bills for days they said my aunt was in the hospital after she had passed away!

Thank you for sharing this. 

TeddyandBears_Mom's picture
TeddyandBears_Mom
Posts: 1807
Joined: Jun 2015

Forherself - thanks very much for sharing this. I will be going on Medicare next year and have been very interested in all posts regarding it.

I'm glad your issue was resolved.

Love and Hugs,

Cindi

Forherself's picture
Forherself
Posts: 595
Joined: Jan 2019

Medicare pays for stays of two days "generally".    And we are supposed to ask if we are admitted.   Ask I don't know who.  And ask every day.  I think that will reduce the risk of that happening.  Yes, we have learned to be our own advocates here.  

 

MoeKay
Posts: 356
Joined: Feb 2004

Hi Sue,

First, I hope you are doing well after your surgery.  I think what you're referring to, and about which the hospital seemed confused, is Medicare's Two-Midnight Rule for coverage under Medicare Part A.  It's complicated, but if anyone is interested, here's some information from the Centers for Medicare and Medicaid Services on the issue: https://www.cms.gov/newsroom/fact-sheets/fact-sheet-two-midnight-rule-0

I was in the hospital overnight last year for a bowel obstruction.  The hospital submitted the approximately $61,000 inpatient claim to Medicare and it was denied in full (I'm assuming under the Two-Midnight Rule).  However, the Medicare EOB states, "Maximum You May Be Billed, $0.00."  So unless you've already paid the $273.00 and don't want to be bothered further at this point, I would suggest contacting your "case manager" and again request that Medicare be billed for your hospital stay and see what they have to say on your EOB.  It may be that you're not responsible to pay the $273.00.  Incidentally, all Medicare Part B claims for the providers I saw while in the hospital as well as all tests were covered. 

I'm one of those members who contacted my federal Congressman when my two insurers refused to pay for my hospital stay for my cancer surgery back in 1999.  I've mentioned this on this board before, but about a year and a half after my surgery, I received a bill from the hospital, letting me know that I could pay  within 10 days using a credit card.  I tried resolving the issue myself to no avail and then sought the assistance of a patient advocate organization.  They were not successful in resolving the matter either.  But my Congressman and his staff were extremely helpful and got the bill fully paid within a few weeks. 

Forherself's picture
Forherself
Posts: 595
Joined: Jan 2019

Yes maybe it was your story that I remembered!  If so it was so helpful, as it is a scary thing to be told you will be paying cash for a surgery.   My letter said "generally" a two night stay is required.  And I would stay the extra night if I do it again.   The $273.00 is just my deductible.   Thank you for. your link.

My back surgery was very successful, and my pain has been totally relieved.  Of course, the pain was a worry about recurrence, but imaging showed no lesions.  Lucky again.

Sharing these stories is so helpful.   

Sue

Fridays Child
Posts: 226
Joined: Jul 2019

Thank you for sharing your story.  I'm especially glad that your surgery was successful!  As you say, many of us are or are about to be on Medicare and it does come with its own set of sometimes confusing rules.  The more we know, the better off we are.

MAbound
Posts: 1160
Joined: Jun 2016

With so many on Medicare, this topic is always helpful when someone has experience to share!

This seems kind of like the gotcha issue of being admitted for "observation" vs being formally "admitted". When you are in an ER for a problem, this catches a lot of people unawares, so I thought this link might be helpful. I have it printed out and keep it in my purse in case of catastrophe so that I can refresh my memory under duress. I hate how convoluted insurance is. It's like they create scenarios just so that you can be denied coverage.

https://www.medicare.gov/what-medicare-covers/what-part-a-covers/inpatient-or-outpatient-hospital-status

TeddyandBears_Mom's picture
TeddyandBears_Mom
Posts: 1807
Joined: Jun 2015

Thanks MABound. I just read that information. Boy, is that confusing! Hope all is well with you.

Love and Hugs,

Cindi

Maxster
Posts: 92
Joined: Apr 2020

Your story of successful advocacy is heart rendering and offers hope.  Not everyone knows how to be their own advocate and just gets intimidated by the system.  It is wrong for things to be so complicated and to have anxiety that a surprise bill might be in the mail.  Your advice is certainly welome on this forum, even for regular insurance.  People can bill insurance directly if the doctor refuses but I am not sure how that would work for Medicare.  You need to know all the billing codes and stuff.  Again, this should not be so hard.  Congratulations on your good outcome.

CancerFreeSunny
Posts: 38
Joined: Sep 2018

Actually, Forherself, it's called "23 hour observation" I have Medicare (due to Renal Failure/Multiple access surgeries) the hospital did bill Medicare and it was covered. When you go in for your surgery and they have you stay the night, and you leave in the morning check-out, Medicare does cover that. It is called "23 hour observation" and that is where you explain to the hospital that you will be only staying the night (in my case, because I had anesthesia and could not drive home. I had no ride oftentimes) You have to get the hospital onboard with it though. They actually came into my room and said I needed to fill out a special form to talk about my brief over-night hospital stay. /requirement from Medicare. The rep agreed it was not considered "in patient" but the 23 hour stay. Next time I would ask about this if you are able. 

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