Valley woman “surprised” after learning Medicare won’t cover cost of nursing home stay

The way some Medicare patients are classified during hospital stays, is often leading to big and costly surprises when those patients leave hospitals.

We spoke with a valley woman who says she endured an “eye opening” experience with her elderly mother.

Palm Desert resident Paula Caplan says she and her mother made a surprise discovery, when her mom, Tac Caplan, was discharged from Eisenhower Medical Center last January, after being treated for a bad fall.

Medicare would not pay for Tac’s long term care in a skilled nursing home after leaving the hospital.

“I was in shock, and I couldn’t believe it was happening the way it did,” said Tac Caplan.

The reason Tac was denied Medicare coverage for a nursing home stay is because she did not meet the requirements.

What the Caplans didn’t realize, is that a Medicare beneficiary must first spend three consecutive days in a hospital as an “admitted” patient before becoming eligible for re-imbursement for a follow up stay in a nursing home.

In Tac’s case, she was discharged from the hospital just before reaching the three day minimum.

She was also never officially admitted.

She was classified as “under observation”.

“If you have been classified as under observation, then Medicare won’t pay anything for a nursing home when you are released,” said Paula Caplan.

The under observation status is one hospitals are increasingly using.

In fact, the practice is up nearly 70 percent over a recent five year period.

Critics say the approach simply allows hospitals and Medicare to pass more costs along to patients.

Not wanting to pay for a nursing home out of pocket, Paula and her mother decided they would live together, so Paula could help her mom recover.

Paula recalled the night she and her mother left the hospital.

“I had four hours to run all around this area trying to find an empty bed, and even one that was half way affordable for this elderly woman who had just been through a traumatic fall,” said Paula.

The Caplan’s say the experience left them frustrated, and said the hospital staff did not fully inform them about the implications of being treated under observation.

Paula wrote a letter to Eisenhower CEO Aubrey Serfling.

Among several requests, she asked the hospital make it standard practice to clearly inform medicare patients whether they’re officially admitted or under observation.

She also requested that patients under observation be made aware they will not qualify for nursing home coverage after leaving the hospital, and will also lose coverage for any medications the hospital provides for pre-existing health problems.

In response to Caplan’s letter, a media relations representative for Eisenhower Medical Center issued a written statement:

“The Centers for Medicare and Medicaid developed very specific and strict regulations regarding observation status for patients. Eisenhower Medical Center complies with these regulations and provides written information to all patients who stay in the hospital under observation status explaining the rules, out-of-pocket costs the patient can anticipate, and resources for more information. Eisenhower works diligently to communicate this information to patients and regularly reviews its processes to ensure that the communication process is effective.

Eisenhower encourages all Medicare patients and their loved ones to educate themselves about observation status before they require hospital care. Visit www.Medicare.gov or speak with an independent Medicare counselor who can explain the impact of observation status on a patient’s potential post-hospital care needs.”

Caplan says her motive for sharing her story is to make other Medicare patients are not caught off guard.

“My mother’s doctor in the hospital for that stay was wonderful, and tried his best to help, but it was just a real shock,” said Paula.

In early August, President Obama signed a bill requiring hospitals to notify Medicare patients when they are receiving observation care, versus being officially admitted.