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Pants on Fire!
HEALTH CARE REFORM DOES NOT CUT MEDICARE BENEFITS
Health care reform does not cut Medicare benefits. In fact, health care reform expands Medicare coverage, by eliminating cost-sharing for preventive services, adding a yearly wellness visit, limiting some cost-sharing in private Medicare plans, and closing the Part D “Donut Hole.” It also improves the solvency of the Medicare program itself.
Health care reform changes some wasteful Medicare payment policies. Some misstated reports of these changes have resulted in exaggerating public fear of cuts to Medicare benefits.
The Affordable Care Act, aka health care reform, achieves savings in the Medicare program through a series of payment reforms, service delivery innovations, and increased efforts to reduce fraud, waste, and abuse. The actual projected reduction in Medicare spending is $428 billion over 10 years, after $105 billion in new Medicare spending is taken into consideration. These projections actually extend the life of the Medicare trust fund by about a decade. None of the payment reforms affect Medicare’s guaranteed benefit packages. Indeed, the law specifically states that the guaranteed benefits in Medicare Part A and Part B will not be reduced or eliminated as a result of changes to the Medicare program.
Health Care Reform Rolls Back The Privatization of Medicare.
Most of the new law’s Medicare “cuts” are actually reductions in subsidies to private Medicare plans, which were begun in 2003 during the Bush Administration. These overpayments to private insurance companies, (known as “Medicare Advnatage” plans) will account for about $130 billion in Medicare savings over 10 years. Medicare Advantage plans are offered by private insurance companies that contract with the government to provide Medicare for people who choose to enroll in a private plan. By law these plans must provide all of the guaranteed benefits under Part A and Part B.
Under the funding mechanism in effect before enactment of the Affordable Care Act, Medicare Advantage plans were paid, on average, about 13% more than the traditional Medicare program to provide the same coverage. These extra payments resulted in Medicare Part B premiums being $3.35 higher per month for all beneficiaries in 2009, and resulted in the federal government (and taxpayers) spending $14 billion more than would have been necessary, if Medicare Advantage enrollees had remained in the traditional Medicare program.
The Affordable Care Act will end these wasteful overpayments by phasing in reductions in Medicare Advantage payments, starting with a payment freeze in 2011. Medicare Advantage payments will be based on national county benchmarks, with plans being paid a fixed percentage of traditional Medicare costs. As a result of this payment formula, plans in some lower-paid counties, generally rural and suburban areas, will continue to receive payments that exceed the traditional Medicare amount, while plans in higher paid counties, many of them large cities, may see substantial reductions. Rebates (an amount plans receive if they bid less than the county benchmark) will also be reduced. The new payment structure also provides for an increase in payments by up to 5% for plans that receive four or more stars for high quality on the CMS star rating system.
Health care reform cuts wasteful payments put in place to encourage private Medicare. Health care reform increases benefits for all people with Medicare, decreases Medicare costs for beneficiaries and taxpayers, and extends the life of the Medicare program.
Health care reform is good for Medicare. Pass it on!
The New York Times Features CMA’s Judith Stein in Its Coverage of Looming Medicare Enrollment Period
Judith Stein, right, executive director of the Center for Medicare Advocacy, with Jocelyne Watrous, a beneficiary consultant. Many private insurers this year are consolidating their Medicare offerings and discontinuing some plans.
From The New York Times:
Medicare enrollment season is approaching, and many experts say they believe it promises to be a turbulent one — “a perfect storm,” said Paul Gada of Allsup, a provider of Medicare plan selection services.
Why? In some areas, there will be dozens, even hundreds, of coverage options. The choices must be reviewed not just by current enrollees and a crush of baby boomers newly eligible for the government-run insurance program, but also by millions of people helping older beneficiaries.
All of them must navigate a system that is changing rapidly, in part because of requirements imposed by the new health care law. “It’s a complicated year for Medicare beneficiaries,” said Judith Stein, executive director of the Center for Medicare Advocacy, a nonprofit group that helps Medicare beneficiaries.
To help simplify the process, you’ll first need a quick rundown of exactly what Medicare entails.
Read the full article, here.
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
Medicare Trustees Attribute Increased Medicare Solvency to Health Reform
The Medicare Trustees issued their annual report today on the program’s financial status. Good news! As a result of health care reform, the Medicare Trust Fund is now expected to remain solvent until 2029 – twelve years longer than the Trustees projected last year. As the Trustees state in their Report, “Nearly all of this improvement … is due to ACA [Affordable Care Act].” While challenges lie ahead, if health reform is fully implemented Medicare has a rosier future and people can count on Medicare being there for them as they age.
Medicare and Medicare beneficiaries, current and future, will benefit from health reform. Now, let’s help get it implemented!
For the full report go to: http://www.kaiserhealthnews.org/Stories/2010/August/05/medicare-trustees-report.aspx
Health Care Reform and Freedom From Fear
By Cong. Joe Courtney (2d District, Connectciut)
No Longer Shut Out of Coverage (Roll Call Op Ed, June 21st, 2010)
I met Gloria Bitner of Marlborough, Conn., at a town hall last year. Now 63 years old, she suffered a heart attack at age 54 and fortunately was covered under her husband’s health plan at the time.
In 2008, however, he was laid off from his job at a car dealership, and their COBRA was close to the end. When I met her, Bitner described in excruciating detail how her heart attack made her family uninsurable on the individual market. After being rejected by a number of insurance providers because of her pre-existing health condition, she turned to Connecticut’s high-risk
pool program. For a basic policy for her and her husband, she was quoted an annual premium in excess of $30,000, which would have obliterated the couple’s middle-class budget.
As the Bitners quickly discovered, in the individual insurance market — where most unemployed and self-employed people and small businesses go for insurance — a heart attack is a common reason for insurance denial.
Another common reason for denial is diabetes. Since their son was diagnosed with Type 1 diabetes, the Crowley family of North Stonington, Conn., has lived in fear of the unforeseen. Although the son is covered through his parent’s employer health plan, the Crowleys worry that if they lose their coverage because of a layoff or job change, his chronic condition will trigger waiting periods or outright exclusion from a new plan. Long term, they worry that he won’t be able to obtain coverage on his own after he ages out of their coverage unless he is lucky enough to find employment with a large firm. Without coverage, they fear he won’t have access to the daily insulin shots and costly glucose monitoring systems he needs to stay alive.
The Crowleys were worried because without a larger employer-sponsored plan, securing insurance coverage on the individual market is almost impossible and prohibitively expensive.
These families are not alone. According to a report released by Families USA, more than 57 million Americans younger than 65 have a pre-existing health condition that leaves them susceptible to insurance denials. For those directly affected by pre-existing condition exclusions, there are clear health and financial consequences. And for families like the Crowleys who are lucky enough to still have coverage, the fear of losing or changing plans takes a toll as well.
An insurance system that excludes people from coverage based on pre-existing conditions functions on the “actuarial rules of risk avoidance.” These rules have an internal logic, but they fail on a societal level by creating a health care system with haves and have-nots. To put it bluntly, it is medical apartheid.
The fact that Type 1 diabetes, a heart attack, high blood pressure, cancer or any other ailment caused by internal biology is used to discriminate in the insurance marketplace is fundamentally unfair.
Now consider a system in which the Crowleys wouldn’t have to think about their son’s employment prospects as a life-or-death situation. Consider a system that ensures access to affordable, meaningful coverage to millions who are susceptible to pre-existing health condition exclusions. Following passage of health care reform legislation, that is the new reality. Jim Crow laws were declared illegal and inherently unfair a generation ago, and denying insurance coverage based on an individual’s internal biology will follow them into oblivion.
Since being elected to Congress nearly four years ago, I have worked to achieve these protections for the Crowley family and for the 57 million Americans who face the crippling effects of pre-existing condition exclusions. In the 110th Congress, I introduced legislation to reduce the practice of denying coverage based on pre-existing health conditions. Then in the 111th Congress, I introduced a bill to eliminate the practice altogether. These protections were included in both the House and Senate health care reform bills and are now the law of the land.
While the new health care reform law will solidify critical insurance reforms to limit and eventually abolish pre-existing condition exclusions, it is not a silver bullet. Protections will be phased in over time. Beginning this year, a new temporary high-risk pool program with subsidized premiums will provide insurance options for those who have been denied coverage based on a pre-existing health condition. Also beginning this year, the legislation will prohibit insurance providers from denying children coverage based on pre-existing health conditions. By 2014, the health care reform package will end pre-existing condition exclusions for everyone.
Over time, these insurance protections will offer sustainable, long-term relief for families like the Crowleys and Bitners. They will eliminate unfair practices and ensure that no one is discriminated against based on his or her internal biology. These protections will put to rest the fear of the unknown. Employment decisions shouldn’t be about life or death, and no family should exhaust its savings paying for insurance. What for so long was a pipe dream is now a reality. It’s the realization of one of President Franklin Roosevelt’s four freedoms, the freedom from fear.
Center for Medicare Advocacy Co-Sponsors Tele-Town Hall With President Obama & Sec’y Sebelius
THE WHITE HOUSE
Office of the Press Secretary
_______________________________________________________________________________________________
FOR IMMEDIATE RELEASE
June 3, 2010
President Obama to Join Seniors for Tele-Town Hall Meeting on Affordable Care Act
WASHINGTON—On Tuesday morning, June 8, President Barack Obama will participate in a national tele-town hall meeting at the Holiday Park Multipurpose Senior Center in Wheaton, Maryland with senior citizens to discuss the Affordable Care Act and efforts to combat senior scams and fraud in advance of the first mailing of the $250 “donut hole” rebate checks. In addition to attendees at the Senior Center, seniors across the country will be able to participate in the town hall meeting by phone. The President will be joined at the town hall meeting by HHS Secretary Kathleen Sebelius and representatives of the following organizations:
AARP
AFL-CIO
AFSCME Retirees
Alliance for Retired Americans
American Association of Homes and Services for the Aging
American Federation of Teachers Program on Retirement and Retirees
American Postal Workers Union Retirees Department
Center for Medicare Advocacy, Inc.
Communications Workers of American Retiree Division
International Union of Painters & Allied Trades – IUPAT
National Academy of Elder Law Attorneys
National Association of Area Agencies on Aging
National Association of State Units on Aging
National Association of Nutrition and Aging Services Programs
National Association of State Long Term Care Ombudsman Programs
The National Caucus and Center on Black Aged
National Committee to Preserve Social Security and Medicare
National Council on Aging
NCCNHR – The National Consumer Voice for Quality Long-Term Care
National Gay and Lesbian Task Force
OWL- The Voice of Midlife and Older Women
SEIU
Service and Advocacy for GLBT Elders
Workers United
These organizations – which together represent over 40 million seniors across the country — will be organizing satellite town hall meetings across the country to dial in and participate in the President’s event, which will be broadcast live on C-SPAN. A detailed list of meeting locations will be released in the coming days.
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.
Politics Trump Health Care for People with Pre-Existing Conditions
The new health reform law encourages states to create or expand existing state high-risk pools as one of the first steps towards insurance market reform and increasing access to health care for people who would not otherwise be able to obtain health insurance. State high risk pools can provide insurance, for example, for people who are receiving Social Security disability benefits but who are in the 24-month waiting period for Medicare.
Citing objections to a “federal takeover” of health care, Georgia’s Insurance Commissioner, John Oxendine, has announced that Georgia will not establish a high-risk pool for its residents with pre-existing conditions. The irony is that the health reform law also provides for the establishment of a federal high risk pool for uninsured people with pre-existing conditions that live in states that don’t have their own risk pool. So, by deciding that Georgia won’t establish its own program, Commissioner Oxendine is guaranteeing a “federal takeover” of health care – Georgia residents who can’t otherwise get insurance will only have the option of insurance through a federal, not state, program.
VG/DC
CMA Health Policy Blog 