Gwynne E. Bodle, Health Coordinator NYSRTA

Here are two articles written by Greg Forbes of Onondaga County. Both are very informative and should be kept in mind when a hospitalization is necessary.

They also underscore the importance of having a Health Care Proxy and Power of Attorney in place. If you are unable to ask and keep asking about your status, you need someone you trust to do it for you and avoid the devastating consequences in these articles.

Article 1

In a report released in May of this year by the IMS Institute for Healthcare Informatics, the organization examined current trends in healthcare, hospital admissions, insurance costs, etc. One of the findings that should be a cause for concern is the number of patients admitted to hospitals from the emergency department spiked for the second straight year climbing nearly 6% in 2012. That is a sign apparently that an increasing number of people are waiting until they are very sick to seek medical care. This may be a direct effect of the number of people who lack adequate health insurance and very possibly due to a continuing tough economy.

Our concern, if we are serious not only about our health care, but also about our financial future, is the way in which these patients are being admitted to the hospital. What has now become a trend and I believe a national tragedy is that many of those individuals entering the hospital either through emergency departments or directly through the admitting office, are not, in fact, being actually admitted, though they and their families believe they are! As opposed to being identified as admitted on an in-patient basis, the admissions office may re-classify them as a patient under observation at any time during their hospital stay. This change in classification may only be for a day or two before being returned to in-patient status. The patient, in either case, will likely not be aware of the changes in their admissions status! Reasons may vary for the patient under observation classification, and may include a pending change in diagnosis, scheduling of additional tests, treatments or any number of other possibilities. The results of this change in classification temporary though it may be, will or may be devastating. For more than five years this sad and unfair policy has been quietly destroying people’s lives. Chances are that most of us don’t know about this because we’re not being told and may likely not find out until we’ve received a medical bill for $40,000 or even more following a hospital stay.

Medicare will normally pay 100% of costs for the first 20 days of skilled nursing care, inpatient rehabilitation, etc following at least three consecutive days as an in-patient in a licensed medical facility. If, however, an individual has, for any reason, been re-classified as under observation for even one day during their hospital stay, Medicare may refuse to pay for any such follow-up care! This may and does apply to other types of followup as well.

44,000 patients were re-classified as “under observation” during hospital stays from 2007-2009, an 88% increase. This trend has continued ever since with tragic consequences for individuals and families at a time when they could clearly least afford it. This change was initiated by Medicare and health care professionals!

What can be done and what recommendations are being offered by AARP and others who are concerned about an aging population and increasing demands being placed upon our health care system? If being admitted to a hospital either through the emergency department or general admission, you are advised to make sure that your doctor has written an order that you be identified as as admitted in-patient not only on the date of admission, but continue to ask everyday during your hospital stay. Ridiculous as this sounds failure to continue to verify your patient status may bring expensive consequences not only now but in the long-run. Our attention to this costly and unfair practice is crucial.

Article 2: Uninvited Surprise Leaves Some Bankrupt

Most of us prefer not to think about or dwell on the need for health care, especially unexpected or urgently needed care for ourselves or family member. When such care becomes necessary, we must trust health care professionals as well as the health care system. Unfortunately, what we don’t know can hurt us!

A report released by the NYS Department of Financial Services in March 2012 raises questions and concerns that need to be part of an open discussion and changes need to be made. According to the report, increasing numbers of individuals are lodging complaints about out of network medical bills. Out-of-network providers may be doctors, hospitals, labs, other health care professionals etc. who have not negotiated reimbursement contracts with the patient’s insurer. In many cases, consumers may do  everything possible, especially in non-emergency cases, to seek in-network doctors and other health care personnel in the event of a need for medical attention. But the study found that increasingly, patients are receiving bills following medical care from doctors, anesthesiologists, even radiologists who are involved in their care, but, unknown to the patients, were out-of-network professionals. The medical bills reported ranged from $110.00 to $31,704 and I one case the consumer got a bill for $83,000 from out-of-network plastic surgeon who had reattached the patients finger. In yet another case, an out-of-network surgeon assisted in a surgery and the individual who had no way of knowing who was in the operating room, received a bill for $7,516. The consumer, in most cases, has no way of knowing in advance if one of the providers involved is out-of-network, according to the report. Yet, bills are increasingly being sent and patients are expected to pay.

In recent conversation with a health care professional whose expertise is medicare, I was told: (1) Almost any insurance company can, and may, wave the rules, after the fact, and patient will not need to pay. But, insurance companies have the right to not wave the rules. (2) New York State has tougher regulations and restrictions than other states. Will they work in your favor? Not always. (3) Patients can and do appeal – a process that may take three or four years often resulting in a denial while their financial future may become increasingly questionable. Is there any hope? I’m not sure but we can keep trying and checking our insurance network before any procedure.