Traverse City Record-Eagle


March 12, 2014

Al Pilong: Two-midnight rule is confusing for patients

TRAVERSE CITY — Hospitals and health care organizations function with several different agencies looking over our shoulder. In a business where people entrust their lives to us, most of this oversight makes sense.

But sometimes the regulators responsible for health care in America act in a way that leaves patients, as well as physicians and hospital administrators, scratching their heads.

A recent ruling by the Centers for Medicare and Medicaid Services (CMS) about who is an inpatient and who is an outpatient seems to be one of those mind benders.

The regulatory agency recently directed that most patients must have conditions medically necessary to require a stay of at least two midnights in the hospital before they are classified as an inpatient.

This leaves physicians who admit patients with the task of trying to predict and justify a patient’s stay at the hospital before all the facts about that patient’s health are known.

Patients, under “observation,” who receive care on a regular hospital unit, sleep in a hospital bed, and order off the patient menu may find CMS will not reimburse certain aspects of their care because they stayed just one night.

Unless these patients are facing scheduled surgical procedures that allow them to be classified as an inpatient, they are in the eyes of CMS regulators an “outpatient.”

This makes them responsible for 20 percent of the cost of diagnostic and lab tests as well as the full cost of any over-the-counter medications they need while in the hospital. These medications cannot be brought into the hospital from home for safety reasons and hospital liability.

When the bill arrives, patients understandably are upset.

Recent reporting on this issue by a national news organization only confused the issue further by inferring that patients can appeal their “observation” status.

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