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Two Tips and Traps

Here is the scenario: Mrs. Green, a widow, is taken by ambulance to the hospital due to a medical emergency.


After she has been treated at the hospital “for a few” days she is not well enough to go home directly from the hospital. With the help of her family, she chooses and is moved to a rehabilitation facility, or rehab unit of a nursing home. The family expects her Medicare benefits to pay 100% of her first 20 days and know that Mrs. Green must pay a daily co-pay of $167.50 from day 21 up to 100 days for her rehab. The family assumes that Mrs. Green’s Medicare Part A will pay for her hospitalization.

Tip/Trap #1: If Mrs. Green was not an admitted patient at the hospital for at least three midnights in a row Medicare will not pay for her rehab. And, for those days she was not admitted, she will be billed under Part B, as an out-patient, which is much more expensive than Part A. The medical records must be read to determine the actual time of admission. Her surroundings provide no clue. For example, she could be in the Emergency Department waiting for a room and be admitted. Or, she could be in a semi-private room for two weeks “under observation” and not admitted (True story). If Mrs. Green is placed “Under Observation” or does not stay for three midnights, she can appeal this decision.


Tip/Trap #2: If Mrs. Green avoided the first trap, watch out for the second trap. Medicare rehab treatment and payments must continue up to the maximum of 100 days as long as Mrs. Green’s medical condition is improving, maintained, or even if her deterioration is slowed or prevented as a result of the rehab services.  If Medicare benefits are stopped too soon, Mrs. Green can appeal.

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