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Ronald Hirsch, MD @signaturedoc
, 20 tweets, 9 min read Read on Twitter
Since @RosenthalHealth brought up the "insist on inpatient" myth again, I thought it was time for a #tweetorial on patient financial obligations. Let me explain it properly.
First, am I qualified to talk about this? Yep, I am the co-author of The Hospital Guide to Contemporary Utilization Review… THe second edition will be published soon. I lecture around the country on @CMSGov regulations.
You can also read my may articles published by @RACmonitor here…

First two terms that are often confused- Copayment= fixed amount payable per episode, such as $30 per visit. Coinsurance= percent owed by patient of total approved amount, such as 20%.
So let's start. First we will start with regular Medicare, which has different rules than Medicare Advantage. And we will start with the Medicare patient who has no supplemental plan. Once you get a supplement, patient liability changes.

We are also talking about 2018, not 2012
In 2013 @CMSGov introduced the Two Midnight Rule. That changed everything. If a study uses pre<2014 information, like the @NEJM article on readmissions published this week, ignore it. It's apples to oranges.
Medicare patients have a $183 part B deductible payable once a year. The first MD visit usually takes care of that. They then owe 20% of approved amount, not of charges. A hospital may charge $6,000 for an MRI but @CMSGov approved is $452 so patient would owe $94, not $1,200.
An Observation stay is paid as a comprehensive APC, which is a mini-DRG- one payment for the whole stay from the ED to discharge. The approved payment is $2,350. (There are some exceptions- read my book for those).
That means for an Observation stay on Jan 1, 2018, the patient owes $183 plus 20% of $2,350 = $653. But if the hospital still charges for self-admin meds (a loophole that @OIGatHHS allows hospitals to avoid… ) then they pay for pills, lets say $400.
That means the Observation patient pays at most $1,053 but maybe $653 if first service or the year but more likely $470.

So what about the inpatient? Well, the inpatient deductible is $1,340 that is incurred on day 1 of an inpatient stay. It resets after 60 days of no inpt care.
So the Medicare patient with no supplement who has not had a recent admission who presents for hospital care would pay $470 for observation or $1,340 for inpatient. Look! Insist on Inpatient = Insist on paying more! Sounds like pretty stupid financial advice to me.
Having a Medicare supplements changes it. There are 10 different supplements. All but two cover deductibles and coinsurance equally.… But most patients don't know if their supplement is A or F or K. So nearly impossible to figure out at the bedside
What about Medicare Advantage? They are (evil) commercial insurance plans that get to make up their own payment rules. @CMSGov doesn't care about payment as long as the patient gets the care they need. Figuring out patient liability is equally impossible. You'll go insane.
Plus, the MA plan determines if the patient is inpatient or observation, usually arbitrarily, sometimes with "criteria," sometimes with midnight counting, sometimes seemingly randomly. The doctor and hospital have little say and the patient absolutely no say.
The MA plans favor Observation because:
1-they pay the hospital a lot less money than inpatient
2-the patient gets the care they need
3-they get to artificially keep their inpatient days per 1,000 enrollees down
Now we can't forget to discuss access to a nursing home, called SNF. @CMSGov has a rule from 1965 that a patient must be inpatient for three days, not counting day of discharge, to qualify for SNF coverage. It's obsolete but it's still the law. Congress is too busy to fix it.
But, you cannot just admit a patient and count three days. They must require care in a hospital. They must require care in a hospital for three days. And they must have skilled needs, not simply custodial needs.

The demented patient with a tired family cannot ask for inpatient.
That demented patient has no hospital needs, no need for three days, and no skilled needs. We could admit them for a week and the SNF still won't be covered. That family needs respite care.
The Two Midnight Rule says if the doctor expects under two midnights of hospital care, they should use observation. So if they expect under two midnights, there is little chance the patient will need three hospital days or have skilled needs. That's the law.
And finally, as many doctors like @choo_ek @DrMichelleLin @efunkEM @DoctorSadieL @jbcowartmd and others said, the rules are the rules. Whether you like them or not, intentionally disregarding a law is not acceptable, whether it is picking patient status, sharing PHI, or speeding,
Absolutely the system is crazy, and it needs fixing (disclosure I am a member of @PNHP) and much of what @RosenthalHealth says in her book is correct, but in the mean time, we have to follow the rules. And telling the patient to "insist on inpatient" is not an option.
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