UNITED STATES—Toni, what is the length of time you must spend in a hospital before Medicare will pay for a skilled nursing stay? My husband has recently spent a month recovering from his stroke and heart surgery. Last week, I received a bill stating that Medicare has denied his stay.  Medicare says he was “not” formally admitted.

Steve went into a skilled facility because I cannot physically take care of him. He is 6 feet and 4 inches tall and weighs 350 pounds and it is impossible for me to lift him. Shouldn’t the hospital have informed me, so I could have had other options? Thanks, Janice – Tampa, FL

Hello Janice: Many are not “formally admitted” into the hospital because of the new “2-day observation rule” until their doctor has finished all the testing, MRIs, scans…etc., and knows what type of medical care or surgery is needed. Until there has been a diagnosis, a person is generally “in observation” and has not been “formally admitted.”

The average person does not know the hospital’s protocol or language, so how would they know the difference between observation or formally admitted. Maybe reality TV should do a TV show on understanding this situation since “the skilled nursing 3-day rule” affects so many unsuspecting Americans who are using Medicare every day. Page 28 of the 2019 Medicare & You handbook explains about the “MOON” document (Medicare Outpatient Observation Notice) which tells if one is an outpatient for more than 24 hours. This may be your situation.

Some may have to pay 100 percent of a skilled nursing and rehabilitative service stay, for themselves or a family member, just as you are experiencing, if they do not have enough days “formally admitted” in the hospital.  The buzz word is “formally admitted” as you have read in your explanation from the Medicare claim.

Review the important information in the Medicare and You Handbook about Skilled Nursing Facility Care:

  • “Medicare covers semi-private rooms, meals, skilled nursing and rehabilitative service, and other services and supplies that are medically necessary after a 3-day minimum medically-necessary in-patient hospital stay for related illness or injury. An in-patient hospital stay begins the day you’re formally admitted with a doctor’s order and doesn’t include the day you are discharged.”

Toni Says®:   Make sure you are formally admitted for at least 4 days… the 3-day hospital stay plus 1 day for being discharged.

-“To qualify for care in a skilled nursing facility, your doctor must certify that you need daily skilled care like intravenous injections or physical therapy.”

This situation has happened to my husband’s father who was hospitalized after he broke his hip on Monday. He had surgery performed Wednesday which was the day he was considered “formally admitted.”  He was moved to a skilled facility 2 days later, on that Friday.  Because he was not “formally admitted” in the hospital for “3 midnight stays” and discharged the next day, he was sent a bill for 100 percent of the skilled nursing facility bill.

When someone is seriously ill and family members are trying to juggle everyday life, you would think that there would be a person at the hospital with the job of making sure that people do not get caught in this situation. Case managers are overloaded just keeping up with the new Medicare rules and guidelines because of healthcare reform.

Many times, the skilled nursing facilities does not realize there is a billing problem until they billed Medicare and the client was never “formally admitted and they owe 100 percent.

More information on Medicare’s MOON notice and other Medicare information at www.ABBS4U.com.

Merry Christmas from Toni King and the Toni Says® team with a $5 discount on the Medicare Survival Guide® Advanced book package special at www.tonisays.com. For those new to Medicare and would like to receive a free consultation call 844-250-8664.