INpatient or OUTpatient?

“Did you know that even if you stay in the hospital overnight, you might still be considered an ‘outpatient’?”

So begins a pamphlet released by Medicare and available at www.medicare.gov.

The difference can be confusing, especially for those who most often qualify for Medicare, the elderly.

The pamphlet suggests that if “you’re in the hospital more than a few hours, always ask your doctor or the hospital staff if you’re an inpatient or an outpatient.”

Why?

Because Medicare Part A (the Medicare that most people do not pay for) “covers inpatient hospital services,” so the patient pays “a one-time deductible for hospital services for the first 60 days” in the hospital. Medicare Part B (medical insurance that a patient generally pays a monthly fee for) “covers most of your doctor services when you’re an inpatient.” Patients “pay 20 percent of the Medicare-approved amount for doctor services after paying the Part B deductible.”

Confused?

You are not alone.

As a hospital “outpatient,” Medicare Part A does not pay. Coverage comes from Medicare Part B. “Generally, this means you pay a copayment for each … hospital service. Part B also covers most … doctor services” if you are an “outpatient.” The patient pays 20 percent of the Medicare-approved part of the bill after they pay the Part B deductible.

Also, drugs (such as those you take on a daily basis) received as an “outpatient” aren’t covered by Part B, but you aren’t allowed to bring those drugs from home. If you have a prescription drug insurance, you can take the invoice you receive after your hospital stay and submit it to your insurance company for reimbursement.

Medicare dictates that if you are “in the emergency department, and then you’re formally admitted to the hospital with a doctor’s order,” you are considered an inpatient, and Part A usually pays for the hospital stay, including emergency department services. Part B insurance pays for doctor services.

If “you visit the emergency department for a broken arm, get X-rays and a cast and go home,” you are considered an outpatient, so Part A pays nothing. “Doctor services and hospital outpatient services” are paid through your Part B insurance.

Those scenarios are fairly traditional as far as “inpatient” and “outpatient” terms have been understood.

The confusing part to consumers is in other circumstances, if “you come to the emergency department with chest pain, and the hospital keeps you for two nights for observation services,” (aka diagnostics); if “you come to the hospital for outpatient surgery, but they keep you overnight for high blood pressure. Your doctor doesn’t write an order to admit you as an inpatient. You go home the next day”; and “Your doctor writes an order for you to be admitted as an inpatient and the hospital later tells you they’re changing your status to outpatient. Your doctor must agree, and the hospital must tell you in writing – while you’re still in the hospital – that your status has changed.”

In all three of these scenarios, even if you slept overnight in the hospital, you are still considered an “outpatient,” and Medicare Part A pays nothing. Your bills will be submitted to your Part B insurance.

Out-of-pocket expenses may be more, but that is not always the case.

“It is very difficult to make an overall generalization about the potential out-of-pocket expense because there are so many factors that can impact it,” explained Kathryn E. Carlson, MSSA, LSW, ACM, director of case management at Warren General Hospital. “In some cases, patients may pay less when they are in observation than if they are inpatient. In other cases they may pay more. The best way to explain it is to use an example. Let’s say a patient comes into the hospital and has only Medicare A and B, no secondary insurance. As an inpatient this patient would pay $1,184 for their inpatient stay. This amount is the part A deductible, and it does change annually, as directed by Medicare. If the patient returns to the hospital after 60 days has elapsed, they will pay this deductible again. The same patient, as an observation patient would pay a $147 deductible, and 20 percent of each approved service. This would include their ER visit if they entered the hospital in that way, imaging, labs, etc. Medicare does allow for hospitals to bill patients for their self administered medications. However, Warren General Hospital has chosen not to pass that expense along to the patient and does not bill for those medications. With regard to the deductible for observation, this amount is annual for outpatient services so if the patient has already paid it they do not have to pay it again until the following year. It also changes annually, as directed by Medicare. A random sample of patients in observation status have charges that average around $212. These charges ranged from a high of $380 to a low of $77. The variation is due to the difference in testing from patient to patient. Someone with a secondary insurance may pay little to nothing out of pocket for either inpatient or observation services, depending upon their specific policy.

“The best advice I could offer would be to have a secondary insurance that covers deductible and coinsurance, and if you find yourself in the hospital or with a family member in the hospital, please ask about your status,” she said.

The most disturbing figures come when a person has to follow up a hospital stay with nursing home care.

If you are a hospital “inpatient” for three or more days, Medicare pays for the first several weeks of nursing home care. As an “outpatient,” Medicare pays nothing for nursing home care. And, most supplemental insurances do not pay for nursing home care.

Warren General Hospital now shares information about Medicare coverage as early as possible in a patient’s time there.

“Currently, WGH patients who begin their hospital stay as an observation patient (outpatient) are provided with the Medicare” information about different statuses, explained Carlson.

“Those who are initially inpatient but then change to observation (outpatient) through the ‘Condition Code 44’ process are provided with that information at the time the change is made, and before their discharge from the hospital.

“Through our performance improvement process we have identified this as an area that is important to reinforce, so the case management staff will also write the patient’s status on the white board in their room,” Carlson continued. “That way, the status is clear from the beginning of the stay, and, if the patient or their family has questions they can ask. We also will be providing all patients, regardless of their initial status, with the Medicare document that explains the differences in status.”

If there is still confusion about a patient’s status, even after their stay at Warren General, they can call for clarification.

“Patients can call the hospital with questions any time, including after they are discharged,” Carlson explained. “Questions can be directed either to patient accounts or case management.”

“Have a secondary insurance that covers deductible and coinsurance,” Carlson advised. “And, if you find yourself in the hospital or with a family member in the hospital, please ask about your status.”