What is Medicare’s 3 Day Skilled Nursing Rule!!

Toni,

            There was an article in the Rancher a couple of weeks ago that addressed the length of time you had to spend at a hospital before Medicare would pay for a rehabilitation hospital. I can’t remember the number of days you have to spend in the hospital. I have a friend just getting into that situation and we want to make sure the bill will be paid by Medicare. I would appreciate you refreshing my memory. Thanks, Johnnie

Hello Johnnie:

            Some may have to pay 100% of their skilled nursing and rehabilitative service stay if they do not have enough days “formally admitted” in the hospital.  The buzz word is “formally admitted” for Medicare to pay for the claim.   The Medicare “rule” or should I say “qualification” is explained on page 35 of anyone’s 2012 Medicare and You handbook.

            Here’s the important information that is on page 35 of the Medicare handbook about Skilled Nursing Facility Care:

  1. “Medicare covers semi-private rooms, meals, skilled nursing and rehabilitative service, and other services and supplies that are medically necessary after a 3-day minimum medically-necessary inpatient hospital stay (which is now in bold font to show how important) for related illness or injury. An inpatient hospital stay begins the day you’re formally admitted with a doctor’s order and doesn’t include the day you are discharged.” *Toni’s tip: Make sure you are formally admitted for at least 4 days…3 the hospital stay plus 1 for day being discharged.
  2. “To qualify for care in a skilled nursing facility, your doctor must certify that you need daily skilled care like intravenous injections or physical therapy”….

 

            Many are not “formally admitted” into the hospital until their doctor has finished all of the testing, MRIs, scans…etc and knows what type of medicare care or surgery is needed.  Until there has been a diagnosis, a person is generally in observation and has not been “formally admitted”.

            The average person does not know hospital’s protocol or language, so how would the average person know the difference between observation or formally admitted.  Maybe reality TV should do a TV show on understanding this situation since “the skilled nursing 3 day rule” affects so many unsuspecting Americans who are using Medicare every day.

            This situation happened to my husband’s father who was hospitalized after he broke his hip on Monday, had surgery performed that same Wednesday, which was the day he was “formally admitted”.  He was moved to a skilled facility 2 days later on that Friday.  Because he was not “formally admitted” in the hospital for “a 3 midnight stays” (you must stay 3 days past midnight to qualify) and the next day was discharged, then he was sent a bill for 100% of the skilled nursing facility bill because of this rule.

            When someone is seriously ill and family members are trying to juggle everyday life, one would think that there would be a person at the hospital with the job of making sure that people do not get caught in this situation. Case managers are overloaded, keeping up with the new Medicare rules and guidelines because of healthcare reform.

             Medicare would say you are sent the handbook and they have notified everyone.  Many skilled nursing facilities do not realize that there is a “3 midnight stays” rule problem until after their client has either been in their facility for a few days or been discharged to go home and billed Medicare.

             That is why I am here to help people understand the maze of Medicare!!

            Toni King is an advocate/consultant for those “Confused about Medicare”.  Email questions to asktoni@medicaretruths.com or call 281/830-3896. Visit her website www.medicaretruths.com. *** I am seeking articles to write concerning healthcare reform and how it has impacted my readers.  Please email me your situations or concerns….Thank you in advance and many blessings…Toni King

 

 

About the Author

Toni KingToni King is a recognized subject matter expert and a passionate advocate for those who are overwhelmed by Medicare rules and requirements. She is a published author (The Medicare Survival Guide), a workshop presenter (Confused About Medicare Workshops) and writes weekly articles for 14 area newspapers. Toni also offers one-on-one consulting services for those who need help sorting through the confusion of the enrollment process and choosing benefits.View all posts by Toni King →

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