Earlier this week, NAHU called on members to take action on our latest Operation Shout to ask Congress to support bipartisan legislation that addresses Medicare’s “two-midnight” policy. Many Medicare beneficiaries are classified as being on “observation,” which can result in significantly higher claims and prevent Medicare coverage from being applied for nursing home care for patients who do not have a three-day inpatient hospital stay. Recently, Senators Sherrod Brown (D-OH), Susan Collins (R-ME), Bill Nelson (D-FL) and Shelley Moore Capito (R-WV) introduced S. 568 and Representatives Joe Courtney (D-CT) and Glenn Thompson (R-PA) introduced H.R. 1421. These bipartisan bills would allow observation stays to be counted toward the three-day mandatory inpatient stay for Medicare coverage of a skilled nursing facility, and NAHU is calling on all agents who work in Medicare to contact their federal legislators and urge them to cosponsor bipartisan legislation that would address this important issue.
Currently, Medicare beneficiaries who are not officially admitted to a hospital may be classified under observation status, which is treated as an outpatient procedure for billing purposes. Unfortunately, the common practice of placing a beneficiary on observation status can have significant financial consequences for Medicare beneficiaries since Medicare Part A and its related coverage rules only apply to actual inpatient-care admissions. This may lead patients, many who are extremely sick and may need skilled nursing care, to spend many days in the hospital and be charged for services that Medicare would have otherwise paid had they been admitted. Furthermore, hospitals have up to one year to retroactively change admission status to observation, leading unsuspecting beneficiaries with thousands of dollars in bills for skilled nursing facility care they believed would be covered by Medicare.
The issue stems from policies designed to prevent unnecessary hospital readmissions, where Medicare would penalize hospitals when patients would be re-hospitalized within a month of being discharged. Hospitals with readmission rates above the national average would receive lower Medicare reimbursements, thereby in theory incenting hospitals to adequately treat patients the first time and avoid re-admissions. However, in response to the policy, some hospitals increasingly placed patients under observation status, allowing them to provide care for patients whose conditions were not poor enough to be admitted without the hospital being penalized for a re-admission. Regardless if care was performed in the inpatient unit, these visits would be classified as outpatient procedures and billed under Medicare Part B, which could result in higher cost-sharing for the patient.
As frequency of beneficiaries receiving extended observation services increased as well as high error rates for hospital services that were performed as inpatient instead of outpatient, in 2013 the Center for Medicare and Medicaid Services (CMS) issued guidance designed to determine which hospital stays should be billed for Medicare Part A and which should qualify as outpatient. Beginning in October of 2013, if a physician expected a patient to stay fewer than two midnights, then the services would be classified as outpatient and billed under Medicare Part B. CMS later delayed the enforcement of this policy through March 31, 2015.
This legislation would help close this loophole and provide an important consumer protection for Medicare beneficiaries who may be placed under observation status. This would allow patients who are placed under observation status to count their stay toward the three-day mandatory inpatient stay under the two-midnight policy for Medicare coverage of skilled nursing facility services, and prevent patients from being denied Medicare benefits. Beneficiaries could also avoid receiving unexpected bills for services, such as prescription medications, that otherwise would have been covered under a hospital admission.
NAHU is calling on all members who work in Medicare to contact their federal legislators and urge them to cosponsor bipartisan legislation that would address this important issue. You can help us spread the message by taking action below:
- Contact your senators and representative. Send an Operation Shout today asking your federal legislators to cosponsor these bills. You can take action here.
- Share your story. As a licensed insurance specialist who works closely with Medicare beneficiaries to help them navigate the impact on their insurance claims and Medicare, stories from your clients about how they have been impacted by the policy will demonstrate the need for this change. We will share your stories with appropriate legislators and staff. You can share your story here.
Take Action today and tell your federal legislators to fix Medicare’s “Two-Midnight” policy!
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U.S. Capitol Switchboard can be reached at (202) 224-3121.