Honored Social Butterfly

MEDICARE - Class Action Lawsuit - Hospital Observation Status and Covered Services - Filing an Appea

Read all about current actions on this Class-Action Lawsuit that was filed against Medicare for just this (Observation classification and Medicare payment) condition and this other twist:
Patients who might want to file an appeal, as they can with many other Medicare decisions. But that is not allowed if the dispute involves observation care.

(08/12/2019) a trial begins in federal court in Hartford, Conn., where patients who were denied Medicare’s nursing home benefit are hoping to force the government to eliminate that exception. A victory would clear the way for appeals from hundreds of thousands of people.

The class-action lawsuit was filed in 2011 by seven Medicare observation patients and their families against the Department of Health and Human Services. Seven more plaintiffs later joined the case.

If they win, people with traditional Medicare who received observation care services for three days or longer since Jan. 1, 2009, could file appeals seeking reimbursement for bills Medicare would have paid had they been admitted to the hospital. More than 1.3 million observation claims meet these criteria for the 10-year period through 2017, according to the most recently available government data.

WOW - if they win, as well they may - OPEN your pockets real wide ! ! !

Sometimes I feel like the Medicare system is controlled by just one term - GOTCHA !

Class-Action Lawsuit Seeks To Let Medicare Patients Appeal Gap in Nursing Home Coverage

It's Always Something . . . . Roseanna Roseannadanna
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Bronze Conversationalist

Maybe this will create a windfall of sorts for patients in this situation, maybe not. Class action suits generally benefit the attorneys more than the "victims".


Medicare isn't the real culprit here. It's the doctors.


Your attending is the one who decides if the patient is well enough to go home or be admitted as an inpatient.


Or admitted for observation.


If the provider "over-prescribes" and says you need to be admitted as an inpatient, and then Medicare denies the claim upon adjudication, the provider(s) won't be paid.


This can happen with any kind of third party payer . . . Medicare, Medicaid, Medicare Advantage, private health insurance . . .


Medical necessity is the rule.


The only way around it is for the patient to pay cash . . . which is impossible for most folks.

The flip side of the argument also has financial penalties.


If the doc says you are well enough to go home but it turns out they were wrong the providers may be required to render follow up care without reimbursement PLUS a negligence claim may follow.


It's really a no win situation.


Medicare (CMS) is doing their best to get folks out of the FFS side and into managed care. Shifting the cost of care away from the government and onto the insurance carriers and patients. This is the way the government saves taxpayer dollars.


At least that is their political pitch for "saving Medicare".


This class action suit is interesting news but I doubt it will result in anything meaningful for Medicare beneficiaries. If Medicare were to relax their rules that would mean higher health care costs for services that may not be medically necessary. 


That in turn is a slippery slope to open the door for other challenges. 


Bark less. Wag more.
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