07 August 2014

Think you understand the difference between "inpatient" and "outpatient?" Think again.

From an eye-opening op-ed column in the Chicago Tribune's Business section:
If you find yourself in a hospital for more than a few hours, make sure you find out if you have been admitted for inpatient care or if you are merely considered an outpatient under what is called "observation care."

If you haven't been admitted to the hospital, the costs you may have to pay out of pocket for medical services and drugs could be considerable. You could also be denied Medicare coverage for follow-up nursing care.

Patients getting emergency department services, observation services, outpatient surgery, lab tests or X-rays, but for whom the doctor hasn't written an order of admission, are considered outpatients even if they spend the night. Even if you stay in the hospital for a few days, don't assume you have been admitted. Ask about your status!

Why are hospitals doing this? In November 2010, the American Hospital Association warned that changes in policy by the federal Centers for Medicare and Medicaid Services "are causing hospitals to place patients in observation status for more than 48 hours instead of admitting them."

The most unpleasant surprise for non-admitted patients is the cost of drugs. Susan Jaffe of Kaiser Health News recently documented examples of patients charged much more for common drugs than they would have paid at a local pharmacy. A patient in Boca Raton, Fla., for instance, was charged $71 for a blood pressure pill for which her neighborhood pharmacy charges 16 cents...

Naturally, an emergency patient isn't thinking about hospital status. However, being an inpatient can mean significant savings to you. So you should ask your doctor to see that you are admitted. In addition, do not hesitate to ask your insurer for assistance in appeals if you believe that the bill you received is incorrect.
More at the source, where there are several relevant links to Medicare resources.  If you or any of your family are likely to be admitted to a hospital, it may be financially very important to you to understand the difference between "observation care" and "admission." I think understanding the details isn't necessary - just knowing that sleeping overnight in the hospital doesn't necessarily mean you're an "inpatient."

This will be of interest only to readers in the United States.  Those of you from other countries probably don't have to worry about this kind of administrative b*llshit.

Addendum:  Reposted from 2012 to add these observations about the deceptive practice of "observation stays" -
Such patients generally have conditions less serious than those requiring admission, but they can remain in the hospital for days, on the same floor as admitted patients. Afterward, they potentially face greater out-of-pocket costs through Medicare and an inability to qualify for nursing home coverage...

...more than 10 percent of stays at [University of Wisconsin] Hospital are observation stays. Nearly 17 percent of the observation stays last more than 48 hours, which Medicare says is supposed to happen in “only rare and exceptional cases.”

Brown University researchers and others say the trend could be fueled by Medicare’s relatively recent fines against hospitals with too many readmissions, or admissions within 30 days of previous ones. If the first stay is an observation, an admission within 30 days won’t be penalized.
More details at the Wisconsin State Journal.


  1. Yes this happened to my family. We all got a HORRIBLE stomach bug (on a weekend of course)...in about 9 hrs I lost 12 lb and my husband lost 16 lb of weight due to fluid loss. We also had a 9 month old child that we took in immediately after he began violently vomiting and passing out. We all stayed in the ER for approx. 12 hours and recieved fluid replacement therapy and anti nausea meds. When we left we paid our co-pay and expected to be charged 5% of the total bill as per our insurance policy. 1 month later we received bills totaling over $7K!!!!!! When we asked our insurance company why they would not pay, they informed us that the ER had reported our visits as "non-emergency outpatient treatment". We ended up fighting it and getting the hospital to change the code, but it still ended up costing us roughly 2K before all was said and done.

    It is a shame, because in 8 years with our insurance provider we only had 1 previous ER visit when my husband was diagnosed with diverticulitis. It is such a shame that hard working people who pay good money for insurance cannot use the policies that they pay out of the nose for because of crap like this. Its enough to make you sick....but no so sick you have to go back to the ER, it would cost you an arm and a leg!!!

  2. The way things are going, we may have to worry about it soon in the UK. The government seems hell-bent on breaking something that's only slightly bent out of shape.

  3. Just wow. On our policy, some stuff is not covered if you go to emergency unless you are admitted. Didn't think the hospital would get it in on preventing that, maybe they don't want the modified pricing from dealing with the insurance companies?

    Interesting story: Recently my mother and a neighbor came down with kidney stones. They went to hospitals across the street from each other. My mother they admitted with a 7.5 mm stone and scheduled her for surgery the next morning. My neighbor was administered pain medication and sent home with a 9 mm stone! They said she had to consult a specialist and only got in well over a week later! An infection prevented my mother's surgery, so they had to wait. She still had hers worked on first and they obliterated it with a laser. My neighbor was done a few days after and they used the ultrasonic machine to break it up... and she is still passing large chunks of stone. Ended up in the hospital again and they once again doped her up on pain meds and sent her home!

    I wonder if this admitting situation came into play for my neighbor.

  4. I feel very fortunate as the last two years my husband was battling with cancer. I would take him to ER, but he would be admitted. Medicare and our Medigap policy took care of all the expenses. There was only one bill which was a blood test that I had to pay for and it was only $34.50. If if were not having those insurances we would have went through our life savings, of course that not only took care of the hospital expenses, but his chemotherapy treatments too.

  5. What we really need is a single-payer system. I doubt we will see it in my lifetime, and maybe not even my children's lifetimes. There's too much money to be made by private insurance companies, as well as doctors and hospitals. We are the only first-world country without such a system. Sad.

  6. I live in the UK, and the other day I was taken to A&E struggling to breathe with a bilateral throat infection, a throat abscess, and glandular fever. I was treated within minutes of arrival, stayed for several days, saw god knows how many specialists and after extensive treatment was eventually discharged with almost 2 weeks' worth of medication. Several follow-up appointments, blood tests and one bout of surgery await me, but the whole thing cost me nothing.
    It's true the NHS needs some TLC, and the way it's changing is worrying, but I for one sleep sounder at night knowing that when this sort of thing happens I will be treated immediately and without question. If this had happened to me in the States I get the feeling I could easily have been bankrupted.

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  8. In 2008 I was admitted after an ER visit revealed I had diabetes.
    Like out of control diabetes, cholesterol too. Since I was admitted (3 day stay),everything was covered by insurance, and my out-of-pocket was pretty minimal.
    But I didn’t understand about the “admitting “ part and a year later I urged a friend to seek care at the ER.
    “Insurance will pay for it” I had told them.
    So they went, and ended up with a 7000 bill because they didn’t get admitted.
    I got that one wrong.
    They still look at me kind of cross-eyed every time I see them.
    I got that one wrong.

    I told a little story last week at my blog that I’m going to link back to this. My story was really about my stubbornness, and the way the Taxpayer picks up these tabs (with and/or without the ACA. This information you posted contributes well to my post..

  9. Every single time I read about the health system in the US, I'm actually horrified and astonished how people can live like that... it's so very different from what I'm used to in Germany. I'm unemployed right now (living on social benefits during an unpaid internship, to be precise), but it's all covered by welfare. Even if I needed to be admitted to hospital for a few weeks right now, I wouldn't have to pay a single cent except a small extra payment of 5€ (about $7) for some prescription meds. When you have a prescription from your doctor, your insurance pays almost everything... and helath insurance is mandatory, so you'd have to be somewhat stupid and/or really lazy to fall out of the system.
    I really can't imagine what it would be like to pay thousands (and probably going into debt for the rest of my life), because I got sick and maybe lost my job in the process... do you actually save some money for cases like this? It seems so very wrong that someone could lose everything because of something random like an illness and not having a thousands of dollars at their disposal right now.

    1. Here- try this one:


      which I may blog separately if I can find the time. This country is crazy stupid about health care finance.

    2. American here: I couldn't believe how easy it is in Germany when I moved. You Germans sure love the paperwork--except for medical care, which is virtually none. The American medical system, in my experience being poor-ish in the US, is as financially predatory as used-car dealers were before lemon laws. You cannot get a price quote or even find out if they take your insurance; I had an insurance company that confirmed they covered Pap smears but didn't cover labs. (The point of a Pap is to do a lab.)

      Yes you can fight it in court, and often they''ll accept much lower payment than originally quoted ($8,000 rather than $20,000 to sew up the stump of my friend's finger). But it's a government-protected cartel, no mistake.


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