Inpatients in "Observation" status vs. admitted

[steelerfan502]

I have recently gone from floor nursing to Care Mgmt. I track pt's hospitalizations as part of an initiative to try to reduce hospital readmits. I know its medicare related, and r/t how/if hospitals get reimbursed when pts are readmitted for the same chronic conditions. And it sounds like theres a correlation between the spike in use of "obs" status by hospitals and the Affordable Care Act. I keep getting half answers and I would really appreciate if someone could spell out for me what the differences are between "observation" status vs. "admitted" status when pts are in the hospital. And why exactly is this happening more and more? And is there a good resource for getting straight answers related to this? What does "observation" status mean to the patients? for the hospitals? To medicare? And is it legal for a hospital to keep a pt in "observation" status for more than 23 hours? When I worked the floor, I got "23 hour obs" pts quite often. But after 23 hours, doesn't their status have to change to "admitted/inpatient?" ANY clear input on this would be SO appreciated!!!

[SummerGarden, BSN, MSN, RN]

Basically, people who have NO REASON to be in a hospital setting for anything other than a very short stay (a few diagnostic to run to medically clear him/her for an outpatient setting) are an OBS patient. Please read the CMS website for clear guidelines. That website makes it clear what is observation (for example the two midnight rule) vs. inpatient.

BTW, lay people are confused and write/speak about OBS vs. Inpatient as if the patient is being treated unfairly if he/she is placed on OBS. This is not true unless there is fraud going on. So, educate yourself so you do not mislead or misguide your patients like a lay person.

FYI, you may have patients ask you to make him/her inpatient to so he/she can go to a SNF for skilled need and have Medicare pay 100%. Tell him/her "No!" because that is fraud! He/she mustb qualify for (meet criteria for) inpatient status to be inpatient. Physical Therapy and/or Occupational therapy for three days with no other acute care need is NOT a reason to be in a hospital setting and so it is not a reason alone to be inpatient. Good luck.

[NanaPrimo]

My experience with status: Medicare criteria, i.e. Interqual, are listed by condition. Criteria for observation status vs. inpatient must be met for reimbursement for that stay. Also, certain surgeries are listed as to what Medicare reimburses for inpatient status vs. observation/outpatient. The observation status means less coverage, but only home medications that are administered during the Obs stay. If the patient has a Medicare replacement plan or supplemental insurance, that might cover the home po meds that are given during the stay. There seems to be a fear tactic within the general Medicare population that the ACA is causing hospitals to treat them unfairly. As CMs, we can assure them that observation is a way to reimburse less, but it also prevents fraud, and hospitals admitting patients with no need to be there. It in no way reduces the quality of care. Medicaid pays 24 hours of observation, private payers differ.