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Quick!
Stop paying anything more to Medicare Advantage plans than to traditional Medicare. Listen to the GAO and stop all bonus payments to private Medicare plans. Start negotiating what Medicare pays for prescription drugs. Then recalculate Medicare’s fiscal solvency and begin serious discussions about Medicare’s future.
Constant calls for changing Medicare into a Voucher system will simply increase privatization of Medicare. Once again we’ll give taxpayer dollars to the insurance industry, increase costs to older people, disabled people, and their familes – and do nothing to address the needs of tomorrow.
Change the conversation. Insist on real solutions.
No Deal is Better Than a Bad Deal
The Center for Medicare Advocacy is neither particularly surprised nor terribly disappointed that the Super Committee did not reach a budget cutting agreement. Many of the Medicare proposals the Committee was considering, such as increasing the age of eligibility and increasing cost-sharing for beneficiaries, would be harmful to the Medicare program and to older and disabled people while not decreasing overall health care costs.
There are ways to strengthen Medicare and reduce costs – such as requiring Medicare to negotiate drug prices, never paying private Medicare plans more than traditional Medicare, adding a drug benefit to the traditional program, lowering the age of Medicare eligibility, and letting the Affordable Care Act do its job. The Center for Medicare Advocacy has long advocated these ideas, and others like them, that would achieve real cost-savings without harming beneficiaries or ending Medicare altogether.
There is still time to secure the financial welfare of Medicare and the country, without doing so at the expense of older, disabled people and their families. There are solutions if those in authority will insist on spending only what is necessary to provide fair health coverage, and refuse spending one dime to change Medicare into a publicly-funded opportunity for private insurance and pharmaceutical companies.
With the end of the Super Committee, decision-makers have a new opportunity to carefully explore such solutions. If politicians find the will, there are ways to save Medicare, meet the needs of its beneficiaries and decrease costs.
Medicare and Jobs: Not Mutually Exclusive!
The more people have health insurance, including Medicare, the more they stay healthy and are able to work. If health insurance is provided by Medicare or health care reform or any avenue outside the tired employer-based system, it reduces costs for employers and encourages hiring. Ask any employer.
Continuing to tie health insurance to employment only continues a system that COSTS jobs. It creates a disincentive for employers to hire. It creates an incentive for the new employment reality: Freelance, contract work, part-time, whatever you want to call the newly underemployed who do not have benefits and for whom employers do not pay into Medicare, Social Security, Unemployment, or Workers Comp. This is a big problem for everyone involved, including individual workers, their families, AND the solvency of important programs that Americans value and that have lifted generations out of poverty and provided fair access to health care.
Pay attention, people! We not only can have Medicare and jobs – we will have more jobs if we increase access to Medicare and health care. Don’t raid Medicare to pay for jobs. That will only reduce access to both.
Medicare Facts & Fiction: 3 More Lessons to Combat Medicare Spin
Congress continues to propose Medicare changes that will have severe repercussions for beneficiaries and their families. Policymakers and pundits are feeding the media and the public misinformation about Medicare. The truth is, most people with Medicare are low-income and most pay more for health care than other insured Americans. Nonetheless, Medicare Works. For 46 years it has opened doors to necessary care for millions of older people, people with disabilities, and their families.
Did you know?
- Medicare beneficiaries already spend a disproportionate share of their income on health expenses. Health expenses accounted for nearly 15% of Medicare household budgets in 2009, on average – three times the percentage of health spending among non-Medicare households (Kaiser Family Foundation Data Spotlight: Health Care on a Budget, June 2011)
- The financial burden of health care costs is greatest for Medicare beneficiaries ages 85 and older, those in relatively poor health, those with low or modest incomes, and those with Medigap supplemental policies (Kaiser Family Foundation Data Spotlight: How Much Skin in the Game is Enough?, June 2011)
- Half of all Medicare beneficiaries had incomes below $22,000 in 2010; less than 1% had incomes over $250,000
- Median per capita income declines with age, and is lower for black, Hispanic, and unmarried Medicare beneficiaries (Kaiser Family Foundation Data Spotlight: Projecting Income and Assets, June 2011)
- Raising the age of Medicare eligibility to 67, as has been proposed recently, will not produce significant savings: according to the Kaiser Family Foundation, most savings to the Medicare program would be off-set by other federal expenditures, and there would be a net increase in out of pocket costs for those age 65 and 66 who would otherwise have been covered by Medicare (Kaiser Family Foundation, Raising the Age of Medicare Eligibility, July 2011)
Surely there are better ways to save money than by piling more onto an already burdened population?
Center for Medicare Advocacy Recommended as Top-10 Caregiver Resource
Jane Gross, creator of The New York Times‘ “New Old Age” blog, recently highlighted the Center for Medicare Advocacy as a top 10 resource for caregivers in an appearance on “Krista Tippet On Being” on NPR. The episode, entitled “The Far Shore of Aging” is garnering an overwhelming response from listeners. See the complete list of resources, and listen to the full show, at http://being.publicradio.org/programs/2011/far-shore-of-aging/gross_topten.shtml.
10 Years of Tax Cuts for the Rich, 10 Years of Increased Debt
June 7, 2011, marked the 10th anniversary of Bush tax cuts that disproportionately benefited wealthy Americans. The rich are opening champagne bottles to celebrate, while advocates for older people and people with disabilities are trying to stave off the cuts to Social Security, SSI, SNAP, Medicare and Medicaid that some claim are needed so that these cuts can continue or even be expanded.
Why are the wealthy celebrating? According to the Center for Budget and Policy Priorities, people with incomes in excess of $1 million saw a 6.2% increase in after-tax dollars as a result of the tax cuts, as opposed to the 2.2% increase experienced by average families earning $40,000-$50,000 per year. The average dollar tax benefit per tax payer for millionaires was $128,832 (or about three times the income of the average family). The average dollar tax benefit per tax payer for the $40,000-$50,000 tax payers was $860.
What’s more, CBPP says that the cost of extending tax cuts for the richest Americans is about the same as the projected Social Security shortfall as a share of the gross domestic product (GDP) over 75 years, .7% for tax cut extensions versus .8% for the Social Security shortfall.
And finally, if the tax cut for the rich was allowed to expire, the increase in the debt would stop over the next 10 years.
So why are we talking about capping spending for programs that help middle and low-income Americans, or turning Medicare into a voucher program and Medicaid into a block grant? The simplest solution would be drink one more glass of champagne for the Bush tax cuts and let them wither away on the vine.
Health Care Reform: A Family Value – Support it!
While some work to repeal Health Care Reform, others are already benefiting from its provisions.
People who have already benefited from health reform are at both ends of the age spectrum. Young and old, they reflect the family value of the law, particularly given these tough economic times when jobs are lost, unavailable, and employers are increasingly dropping benefits.
Here are some stories the Center for Medicare Advocacy has heard in just the last day:
1. A Connecticut State Health Insurance and Assistance Program (SHIP) counselor writes: “I know a lot of our seniors will benefit from the government slowly getting rid of the Donut Hole in prescription drug coverage.” This is echoed by many others including:
• An older Connecticut woman and her niece, from Delaware, both went into the Donut Hole in 2010 and both received $250 as a result of health care reform to help out.
• A gentleman from Florida reached the Donut Hole in both 2009 and 2010, and expects to do so again in 2011. He appreciated the $250 help in 2010 and, given his heart and other health problems, he will certainly benefit from health reform’s 50% discount on Brand name drugs in 2011.
2. Another individual writes:
• “I have a sister who is 25 years old and was unable to find a job that would provide health care coverage due to the economy. She has very serious ear problems and required two major surgeries to replace her ear drum in both ears. If she was not able to be on our parents’ health insurance plan, she would not have been able to afford the surgeries and would have gone completely deaf. It is very difficult to be a young person out of college during these times. Even if you can find a job, it is very difficult to find a full time job with health benefits. I consider myself extremely lucky that I did find a job with benefits, but do know many who had no health insurance for some time. These young people need the cushion of being on their parents’ insurance until 26 when they can find a stable job with health benefits because in this economy, less and less employers are offering benefits to young people.”
The importance of health reform allowing young adults to obtain coverage on their parent’s health insurance plan is reiterated by another individual:
• “ I can personally speak for the kids 26 and under part of this. I have two kids under 26. One does not live at home. He is 22 and working at a job without health insurance. He would have no health insurance without being able to stay on my insurance. He was able to have an expensive blood test to find out if he has a potentially life threatening blood disorder because he had my health insurance to cover it.”
3. Four of the Center for Medicare Advocacy’s own employees have young adult children who have lost their jobs or are employed, but their employers do not provide health insurance. Again, these young people only have health insurance as a result of health care reform which allows them to be covered by the Center’s health insurance. At least one of these young adults has an on-going mix of mental health and medical problems that require on-going health care.
Health care reform is helping families struggling to deal with illnesses, age, unemployment, and underemployment. The law advances family values.
Vote!
As if Medicare and your health depend upon it.
Health Care Reform: Standing Up To Insurance Companies and Standing Up For People
OPINION – Wall Street Journal, SEPTEMBER 28, 2010
Health Insurers Finally Get Some Oversight
By KATHLEEN SEBELIUS, Secretary of Health and Human Services
In the last two weeks, my department has been accused of “thuggery” (this editorial page) and “Soviet tyranny” (Newt Gingrich). What prompted these accusations? The fact that we told health-insurance companies that, as required by law, we will review large premium increases and identify those that are unreasonable.
There’s a long history of special interests using similar attacks to oppose change. In the mid-1960s, for example, some claimed Medicare would put our country on the path to socialism.
But what is really objectionable about these comments is not who they’re attacking, but what they’re defending. These critics seem to believe that any oversight of the insurance industry is too much, and that consumers would be better off in a system where they have few rights or protections.
Over the past decade, Americans have seen what happens when insurance companies have free rein. The cost of health insurance has more than doubled, while millions of hard-working Americans lost their coverage or drained their savings to keep up with premiums. Employers, big and small, have struggled mightily to absorb these cost increases and have been losing the fight.
As insurance commissioner and governor of Kansas, I saw firsthand how these rate hikes burdened people. I spoke with families who watched their insurance go up 20%, 30%, even 40% a year without explanation. I met with small business owners who had stopped offering health insurance to their employees because they couldn’t afford the annual double-digit premium increases.
A woman who wrote to me recently summed up the frustration that many feel. “As a self-employed, hard-working person,” she wrote, “I have no good options for health coverage.”
Yet even as our insurance markets have failed Americans time and time again, special interests successfully blocked reform. That’s changing with enactment of the new health insurance law. Under the Affordable Care Act, 46 states have already received grants to beef up their premium-review and oversight capabilities. And additional funding is on the way.
The law also gives clear instructions to the new state-based health insurance marketplaces called exchanges that will be created in 2014. As the exchanges decide what plans to include, they must incorporate recommendations from states about whether particular health insurance issuers should be excluded based on a pattern of excessive or unjustified premium increases.
We are already seeing this new level of accountability pay off. Last week, North Carolina’s largest insurer announced a “one-time refund that will return $155.8 million to more than 215,000 individual Blue Cross Blue Shield customers as a result of the Affordable Care Act.” This rebate will put an average of $720 back into the pockets of each of those policyholders. In addition, thanks to diligent work by North Carolina’s insurance commissioner, they’ll see their premiums rise by less than 6% in 2011, thesmallest rate increase in four years.
A day after Blue Cross Blue Shield’s announcement, seniors with private Medicare plans got some news that most Americans haven’t heard in years: Their premiums will actually go down 1% next year, even as many of them enjoy better benefits.
The Affordable Care Act is bringing some basic fairness to our health insurance market. So when I learned that a handful of insurers around the country are blaming their significant rate increases on the new law, even though the facts show that the impact of the law on premiums is small, just 1% to 2% declining over time‹I let them know that we’d be closely reviewing their rate hikes.
It’s understandable that some insurance companies and their allies don’t welcome this change. They’ve made large profits from the status quo. And it’s not surprising, though still disappointing, that House Republicans have recently pledged to repeal the Affordable Care Act and get rid of these new consumer protections.
If critics really want to go back to the days when insurance companies ran wild with no accountability, they should have the courage to say so openly instead of hiding behind distracting attacks. In the meantime, we’re going to keep standing up for American families and small business owners who deserve a system that works for them.
Ms. Sebelius is the U.S. secretary of Health and Human Services. http://online.wsj.com/article/SB10001424052748704082104575515851336184716.ht
When Is a Hospital Inpatient Stay Not an Inpatient Hospital Stay – Hospital “Observation Services”
We introduce our readers to a new topic today: Being in a hospital bed in a Medicare-participating hospital is no guarantee that a Medicare beneficiary is an inpatient. In the Center for Medicare Advocacy’s December 11, 2008 Alert, we described the increasingly common practice of placing Medicare beneficiaries in acute care hospital beds and calling them outpatients, on “observation status.”[1] It may sound like Alice in Wonderland or 1984 or some other fiction. Unfortunately – it’s not.
Beneficiaries who remain in hospital beds for multiple days, or even weeks, receiving physician and nursing services, tests, medications, food, and supplies, are in many instances nevertheless identified as outpatients. One major consequence of outpatient status is that beneficiaries are denied coverage for a subsequent stay in a skilled nursing facility (SNF) on the grounds that they have not been inpatients in the hospital for three or more consecutive days. Beneficiaries receiving outpatient observation services, which are covered under Medicare Part B, are also billed for services such as prescription drugs that would ordinarily be covered under Medicare Part A during an inpatient hospital stay. Placement in observation services has the effect of shifting significant health care costs that should be covered under Medicare Part A from the Medicare program to Medicare beneficiaries.
At the same time that the use of observation services is becoming more extensive by hospitals throughout the country, some beneficiaries who have appealed the denials of their hospital stays have been successful. This Alert describes a new brochure from the Centers for Medicare & Medicaid Services (CMS) – CMS’s first description of observation services for beneficiaries. It also discusses three recent favorable decisions – two at the Administrative Law Judge level of appeal and a third at the level of the Qualified Independent Contractor (QIC), Maximus Federal Services. A fourth case, which is not about observation services, addresses the InterQual criteria and process that are used by hospitals to determine whether a patient is receiving inpatient care.
What are Observation Services?
Observation services are defined in Medicare’s manuals as a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.[2]
The Manuals suggest that a patient may not remain in observation status for more than 24 or 48 hours.[3] Since 2004, CMS has authorized hospitalization utilization review (UR) committees to change a patient’s status from inpatient to outpatient, retroactively, if (1) the change is made while the patient is still hospitalized; (2) the hospital has not submitted a claim to Medicare for the inpatient admission; (3) a physician concurs in the UR committee’s decision; and (4) the physician’s concurrence is documented in the patient’s medical record.[4] CMS anticipated that retroactive reclassifications would occur infrequently, “such as a late-night weekend admission when no case manager is on duty to offer guidance.”[5]
CMS Brochure
A new six-page CMS brochure entitled “Are You a Hospital Inpatient or Outpatient?”[6] begins with the statement, “Did you know that even if you stay in the hospital overnight, you might still be considered an ‘outpatient’?” The brochure suggests that patients who are in the hospital for “more than a few hours” ask their doctor or hospital staff if they are inpatients or outpatients.
The brochure incorrectly suggests in two places that decisions to place a beneficiary in observation are made by the beneficiary’s own physician.[7] In fact, this is often not the case; CMS allows any physician to confirm a decision by a hospital’s UR committee to reverse an inpatient admission decision made by an attending physician.
Even more significant, while the brochure may give beneficiaries notice of their status as observation patients, it does not give them any rights to challenge their placement in observation. The brochure’s discussion of “rights” says only that beneficiaries have the right to “get a review of (appeal) certain decisions about health care payment, coverage of services.”
The brochure may have the effect of discouraging beneficiaries from appealing their placement in observation services if they erroneously believe that their attending physician ordered observation services. As discussed below, the Center encourages beneficiaries and their advocates to appeal observation decisions, regardless of whether the decisions are made by attending physicians or hospitals’ UR committees. Moreover, despite the lack of clarity about beneficiary appeal rights,[8] some beneficiaries have filed appeals and prevailed.
Favorable Decisions
In January 2010, Administrative Law Judge (ALJ) P. Arthur McAfee overruled a decision by Maximus Federal Services and held that a Medicare beneficiary’s entire five-day stay in an acute care hospital should have been covered by Medicare Part A.[9]
The beneficiary’s physician had ordered that she be admitted “for inpatient care secondary to a diagnosis of an L1 compression fracture.” Her condition was “fair” and she required monitoring, assessment, and intravenous fluids, including multiple doses of intravenous morphine. On her third day in the hospital, October 25, 2008, she was notified that her status was being changed from inpatient to outpatient. On appeal, the Quality Improvement Organization (QIO) found that inpatient coverage was appropriate for days three through five, October 25-27. The QIO did not review the beneficiary’s observation status for the first two days of her hospital stay. On appeal, Maximus issued an unfavorable decision, finding that the claim had already been processed for payment.
The ALJ cited the Medicare statute and two Manual provisions as guiding his analysis. First, he cited the Medicare Benefit Policy Manual, which describes the decision to admit a patient [as] a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient’s medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital’s by-laws and admissions policies, and the relative appropriateness of treatment in each setting.[10]
Relevant factors to be taken into consideration include “the severity of the signs and symptoms exhibited by the patient,” “the medical predictability of something adverse happening to the patient,” “the need for diagnostic studies that appropriately are outpatient services,” and “the availability of diagnostic procedures at the time when and at the location where the patient presents.”[11] He also cited Chapter 1, §10 of the MBPM, which uses “a 24-hour period as a benchmark” and wrote, “physicians should order admission for patients who are expected to need hospital care for 24 hours or more.”
The second Manual relied on by the ALJ was the QIO Manual, which gives guidance to QIOs on reviewing inpatient hospital admission decisions and directs a physician reviewer to “consider, in his/her review of the medical record, any preexisting medical problems or extenuating circumstances that make admission of the patient medically necessary.”[12] Inpatient care is “required only if the patient’s medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting.”
Applying these criteria, the ALJ reversed Maximus’s denial of inpatient status for the beneficiary’s entire five-day stay, finding “The documentation provides no foundation to go against the judgment of the admitting physician.”
A second favorable decision, issued by Maximus on November 10, 2009, involved “a 79-year old man who presented to the emergency room (ER) from his assisted living facility with progressive altered mental status over the prior week.”[13] The man had been “fully oriented,” but at the time he was brought to the ER, he was “quite disoriented” or delirious.
The Maximus decision recognized that “Delirium represents an acutely life-threatening condition, evaluation and management of which can be complex and extended.” Although it turned out that the management of the patient was not complex, Maximus wrote, “it was not reliably predictable at the time of admission that the necessary work-up of the balance of the differential diagnosis would have been able to be completed within a reasonable period of hospital observation.” Relying on the Medicare Benefit Policy Manual, Pub. 100-2, Chapter 1, §10, the same provision relied on by the ALJ in the decision discussed above, and on the Program Integrity Manual, Pub. 100-8, Chapter 8, §6.5.2,[14] Maximus authorized inpatient hospital coverage for the entire five-day period.
A third decision addressed the denial of coverage for a 30-day stay in a SNF because of the absence of a three-day prior hospital stay, despite the fact that the beneficiary, classified as an outpatient receiving observation services, had been hospitalized for 13 days. Following a telephone hearing, ALJ Michael D. Bartko ruled both that the beneficiary met the three-day qualifying hospital stay required for SNF coverage and that she needed and received Medicare-covered care in the SNF.[15]
The fourth decision addressed whether a Medicare Advantage beneficiary’s inpatient hospital admission ended, as set out in the Notice of Denial of Medicare Coverage, or should continue.[16] The ALJ discussed the hospital’s reliance on InterQual criteria, which are also used in observation cases to determine whether a beneficiary should be classified as an inpatient.
At the ALJ level, the hospital was required to produce the patient’s complete medical records, the CareEnhanced Review Manager Enterprise (CERME), and the InterQual/McKesson Manual. The ALJ found “a significantly limited independent review of the approximately 6000 pages of medical records in this case [italics in original]” by the QIO physician who cited physical therapy notes, wound care notes, and a single physician note in upholding the discharge notice. He then described the InterQual Manual and CERME as proprietary tools that are used for various purposes, including “coverage denial management programs.” He wrote, “Information is obtained from patient medical charts and from other captured data which is input into a software program that generates a summary report.” Although the ALJ sealed the InterQual and CERME documents because they were proprietary, he found that “the inputs are very subjective” and that, in this case, they were “inconsistent with the known medical treatment” provided to the patient, as described in her medical records. He concluded that the patient’s inpatient stay was medically necessary and that Medicare coverage properly continued after the beneficiary received the notice denying further coverage.
What Should Beneficiaries and Their Advocates Do?
The Center for Medicare Advocacy suggests that beneficiaries file an appeal from any hospital notices describing their observation status and any subsequent Advanced Beneficiary Notice/Notice of Exclusion from Medicare Benefits they receive from a SNF.[17] In the likely absence of any notice, particularly from a hospital, the Center recommends that beneficiaries appeal when they receive the Medicare Summary Notice, which sets out all health care services received by a beneficiary in the prior quarter.
In all cases, beneficiaries and their advocates should gather the complete medical records from the hospital to establish the entire set of services and treatments that were received during the period of hospitalization. Advocates should request copies of all documents used by the hospital, its UR committee, and outside consultants to determine beneficiaries’ status. Advocates should present the medical and nursing facts and cite any physician support for inpatient status to demonstrate that the beneficiary met Medicare’s criteria for an inpatient stay. If SNF coverage is also at issue, advocates must demonstrate not only that the beneficiary met the criteria for Medicare-covered care in the SNF but also that the beneficiary received Medicare-covered care in the SNF.
Advocates should not be discouraged if they lose at the early stages of appeal: reconsideration, QIO, and QIC review. Three of the four cases discussed in this Alert were won later, at the ALJ level.
Continuing Work
The increasing use of administratively-created observation services is undermining the Medicare Part A hospital benefit, which authorizes inpatient hospital care for both diagnosis and treatment,[18] by essentially redefining diagnosis as observation under Part B. Observation services also violate the Medicare statute by allowing hospital UR committees to issue retroactive and binding determinations that a patient, admitted to inpatient status by the patient’s attending physician, is instead receiving observation services.[19]
The Center for Medicare Advocacy is interested in hearing from advocates, beneficiaries, and providers about their experiences with hospital Observation status, including issues stemming from the lack of notice and the inability to use existing appeals processes.
For more information, or to share an experience with observation services, contact attorney Toby S. Edelman (tedelman @ medicareadvocacy.org) in the Center for Medicare Advocacy’s Washington, DC office at (202) 293-5760.
[1] “When Is a Hospital Stay Not a Hospital Stay? When the Patient Is in ‘Observation Status,” (Dec. 11, 2008 Weekly Alert), http://medicareadvocacy.org/InfoByTopic/SkilledNursingFacility/SNF_08_12.11.ObservationStatus.htm.
[2] Medicare Benefit Policy Manual, CMS Pub. 100-02, Chapter 6, §20.6; same language in Medicare Claims Processing Manual, CMS Pub. 100-04, Chapter 4, §290.1.
[3] Id.
[4] Medicare Claims Processing Manual, CMS Pub. No. 100-04, Chapter 1, §50.3, originally issued as CMS, “Use of Condition Code 44, ‘Inpatient Admission Changed to Outpatient,’” Transmittal 299, Change Request 3444 (Sep. 10, 2004).
[5] CMS, “Clarification of Medicare Payment Policy When Inpatient Admission Is Determined Not To Be Medically Necessary, Including the Use of Condition Code 44: ‘Inpatient Admission Changed to Outpatient,’” MedLearn Matters (Sep. 10, 2004), now at Medicare Claims Processing Manual, CMS Pub. No. 100-04, Ch. 1, §50.3.
“Use of Condition Code 44 is not intended to serve as a substitute for adequate staffing of utilization management personnel or for continued education of physicians and hospital staff about each hospital’s existing policies and admission protocols. As education and staffing efforts continue to progress, the need for hospitals to correct inappropriate admissions and to report condition code 44 should become increasingly rare.” Question and Answer 3.
[6] CMS Product No. 11435 (Dec. 2009), http://www.medicare.gov/Publications/Pubs/pdf/11435.pdf
[7] “Your doctor may order ‘observation services’ to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged,” page 4; and fifth example in the chart, page 3, indicates that if “your doctor” admits you as an in-patient and the hospital later changes your status to out-patient, “your doctor must agree.”
[8] The Center’s December 11, 2008 Weekly Alert addressed various notices that beneficiaries might receive advising them of appeal rights. See footnote 1, supra.
[9] ALJ Appeal No. 1-517883673 (Jan. 8, 2010), available at: www.medicareadvocacy.org\InfoByTopic\ObservationStatus\Decisions\VT_ALJ_01.10.pdf.
[10] Pub. No. 100-2, chapter 1, §10.
[11] Id.
[12] Pub. No. 100-10, chapter 4, §4110.
[13] Medicare Appeal No. 1-496442359 (Nov. 10, 2009), available at: www.medicareadvocacy.org\InfoByTopic\ObservationStatus\Decisions\MN_Maximus_11.09.pdf.
[14] The ALJ described the Manual as requiring medical reviewers to “consider any pre-existing medical problems or extenuating circumstances that make admissions of the beneficiary medically necessary.”
[15] ALJ Appeal No. 1-380068132 (April 9, 2009) available at: www.medicareadvocacy.org\InfoByTopic\ObservationStatus\Decisions\WI_ALJ_04.09.09.pdf.
[16] ALJ Appeal No. 1-424979831 (Dec. 9, 2009), available at: www.medicareadvocacy.org\InfoByTopic\ObservationStatus\Decisions\CA_ALJ_inpatient_InterQual_12.09.pdf.
[17] http://www.cms.hhs.gov/BNI/Downloads/CMS20014.pdf
[18] The Medicare statute defines “hospitals” as providing both diagnostic and treatment services to inpatients. 42 U.S.C. §1395x(e)(1)(A). It similarly defines “inpatient hospital services” to include diagnostic or treatment services. 42 U.S.C. §1395x(b)(3).
[19] 42 U.S.C. §1395.
