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Your Pocketbook - Same Surgery, Same Place - Different Bill & Out of Pocket Cost

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Your Pocketbook - Same Surgery, Same Place - Different Bill & Out of Pocket Cost

Those of you on Medicare need to be aware of this new Medicare rule if you are contemplating some surgery with your doc and it is being planned as a (hospital) outpatient surgery. This could get fixed; but who knows how long it will take -


Kaiser Health News: 03/23/2021 - Under New Cost-Cutting Medicare Rule, Same Surgery, Same Place, Dif...


I will try to summarize as much as I can.

The issue at bay is which Part of Medicare will pay for these types of (hospital out-patient) surgery - Medicare Part A or Medicare Part B.


Medicare classifies surgeries under in-patient and out-patient. Of course, those that are more dangerous or extensive are done on an in-patient basis, where the beneficiary is actually admitted to the hospital.  Others are deemed less dangerous and can be done as out-patient. Medicare Part A pays for hospital in-patient (admitted) care and Medicare Part B pays for out-patient care.


Medicare defines out-patient care as expected to be released within 24 hours. Beginning in 2021, several more surgeries have been added to the list of approved out-patient basis and more may follow. The problem is (see the KHN link) while removing the surgeries from the inpatient-only list, the government did not approve them to be performed anywhere else. So patients will still have to get the care at hospitals. But because the procedures have been reclassified, patients who have them in the hospital don’t have to be considered admitted patients. Instead, they can receive services on an outpatient basis.


CMS (Medicare) pays hospitals less for care provided to beneficiaries who are outpatients, so the new policy means the agency can pay less than it did last year for the same surgery at the same hospital and Medicare outpatients will usually pick up a bigger part of the tab.

So just as a heads-up - when you and your doctor are scheduling a surgery - make sure you know what your status will be if it is being done in a hospital - are you in-patient or outpatient - and know what your follow up care (recuperating) will be and what your financial obligations will be under Medicare (who pays Medicare Part A or Medicare Part B).

Hopefully, CMS will correct this shortly - they will just add that under these (out-patient) procedures, they don't have to be done in a hospital - they can be done in other types of ambulatory surgical centers.


It's Always Something . . . . Roseanna Roseannadanna
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