A patient can stay in a hospital in a semi-private room, receive meals and general nursing, and even have surgery, however inpatient vs outpatient hospital stay get different medical services and will probably pay different amounts.
as seen in the Courier Life newspaper: September 1, 2015
When is a hospital stay not a hospital stay? Does this sound like a trick question? Unfortunately it is not and the answer can be costly and impact your medical care.
Many seniors are unaware that there are two kinds of hospital stays; a person can stay in a hospital as an inpatient or as an outpatient. In both cases you may stay in a semi-private hospital room, receive meals and general nursing, and even have surgery, however an inpatient will be offered different medical services and will probably pay less than an outpatient.
A hospital inpatient is someone who is formally admitted to a hospital through a doctor’s written order. The doctor writes an admission order if she feels a hospital stay is essential for the patient’s recovery.
A hospital outpatient is someone who enters the hospital, usually through the emergency room, and is considered under observation only. An outpatient can receive lab tests, X-rays and other hospital services but these services are administered to determine if he needs to be formally admitted.
Inpatient vs. Outpatient Hospital Stay
Despite the similarities in services, a patient’s status can make a big difference in what you pay and what services you can receive. Here are the biggest differences.
Seniors admitted to a hospital as inpatients are covered under Medicare Part A, the U.S. Government’s hospital insurance plan. After an initial deductible of $1260, Medicare Part A pays the cost of a semi-private room, all meals, general nursing care, and miscellaneous hospital services and supplies for up to 60 days.
Seniors who stay in a hospital for observation are classified as outpatients and are covered under Medicare Part B, the government’s medical insurance plan. Outpatients must pay an annual deductible of $147, and are then responsible for 20% copayments for every medical service received. These expenses often total more than the Medicare Part A deductible.
The cost of medicine is different for inpatients and outpatients. Inpatients have their medications paid through Medicare Part A. Outpatients must pay for medications out of pocket or through a Medicare Part D prescription drug plan. There is one more catch—if the Part D plan does not cover the drugs that are prescribed, the patient is required to pay for them himself.
A final difference between inpatients and outpatients is in the follow-up service. An inpatient who stays in the hospital for at least three days is eligible for rehabilitation services such as physical, occupational, and speech therapy in a skilled nursing facility (SNF). The first 20 days of rehab in a SNF is covered completely by Medicare Part A. After 20 days the patient is responsible for 20% of the cost for up to an additional 80 days. During that stay, the patient receives two therapy sessions every day except weekends, is provided with three meals a day and gets care from certified nursing assistances, nurses and dietary staff.
Hospital outpatients are not eligible for a rehabilitation services in a nursing home facility without paying for the stay. An outpatient could be eligible to receive some rehab services at home or in a clinic through Medicare Part B, but the rehab is less intense. The patient may see a therapist one to three times a week, but will not receive other services such as meals, housekeeping, or attendant services.
How to Determine an Inpatient vs. Outpatient Hospital Stay
A rule of thumb in determining your patient status depends on how you enter the hospital. If you enter the hospital through the emergency room you are probably classified as an outpatient, at least until a doctor officially admits you or sends you home.
You are also not an inpatient if you enter the hospital for outpatient surgery. You might be told you can stay in the hospital over night and still not be admitted. The best way to determine your status is to ask questions. Every time you receive a treatment be sure that you now how it will be billed, through Medicare Part A or Part B.
Fortunately a solution to this confusion is in sight. On August 6, 2015 President Obama signed a new law called the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act. The new law will go into effect in August 2016. It require that hospitals to notify patients who are under observation for more than 24 hours of their outpatient status.
NOTICE is intended to prevent Medicare beneficiaries from spending days in a hospital only to find that they have not been admitted to the hospital at all but were only under observation. This is particularly valuable for people who need rehabilitation therapy after their hospital stay.
Hospital stays are never pleasant and are often filled with concerns. The added confusion of not understanding your medical status or care options can make your stay seem even more overwhelming. By asking the right questions and understanding your rights, you can help improve the outcome.