High cost, rigorous rules can trap Medicare patients
Rachel Bogom (right) and her mother, Fran. Rachel Bogom had to plead with doctors and officials at Abington Memorial Hospital to find some way to let her mother stay in the hospital long enough to qualify for Medicare rehabilitation payments.
HEALTH
On the evening of Jan. 3, Fran Bogom, 86, a resident of the Abramson Center for Jewish Life in Horsham, was sitting on her bed watching television when she dozed off, fell, and broke her arm.
Bogom, a widow with mild dementia, arrived at the Abington Memorial Hospital emergency room at 9:21 p.m.
Doctors decided to keep Bogom overnight, placing her in observation status, essentially making her an outpatient, and figure out the best plan in the morning.
If Bogom were covered by Aetna, Blue Cross, or another private insurer, she might have been approved right away for a move to a nursing home, to help her get better.
But Bogom had Medicare.
And because of a regulation dating to 1966, Medicare would not pay for her rehabilitation in a nursing home unless she first stayed in the hospital for three days.
If Bogom stayed only one day at Abington, or two, she would have to pay the rehab bill herself. Her family feared it might be $5,000, even $10,000. It turned out to be far more.
So the stakes were high. Could she stay put at Abington for three days?
A predicament in context
To appreciate Bogom's predicament, which has arisen in virtually every American hospital, one needs to see it in context.
The new health bill - besides expanding insurance coverage - triggers many experiments to deliver better care at less cost. But redesign will take years, if it is even possible.
More immediately, America faces soaring health costs.
Medicare spent $509 billion last year on care of America's elderly. More money flows out every year, so the agency running Medicare is becoming more rigorous in policing payments to hospitals and doctors.
It has empowered teams of auditors - review audit contractors, known as RACs - to examine hospital claims.
Most private insurers follow patients in real time, often requiring authorization for procedures, tests, and drugs.
Medicare is different. It sets out exhaustive rules, and hospitals, doctors, and rehab facilities promise to code and bill accurately.
If Medicare finds that a hospital billed for a patient who did not need to be admitted, or failed to document a claim, it can refuse payment for the entire stay and impose a fine. Even if the mistake was unintentional.
At Abington, six nurses inspect patient charts daily to ensure the best care and to make sure each has the documentation to satisfy Medicare and other insurers.
Also, a utilization committee reviews whether people like Bogom need to be there.
And if they don't, the hospital tries its best, within the bounds of patient safety, to discharge patients to a more appropriate setting.
"We're just trying to follow the rules," said Michael Walsh, Abington's chief financial officer. "If you don't, there's a heavy hammer that comes down on you."
Abington must have resources to maintain staffing, operate clinics, renovate buildings, buy the latest equipment, recruit top doctors.
Abington leaders believe that if they don't comply with regulations to the letter, especially with the arrival of the RACs, millions of dollars are at stake - enough to turn a healthy hospital into one that can't fulfill its mission.
Formally admitted
On Monday morning, Jan. 4, Daila Pravs, a family physician, visited Bogom and formally admitted her.