SIOUX FALLS, S.D. - Medicare is a federal health insurance program that assists people who are 65 or older. Individuals with disabilities can also be eligible for the insurance. If a patient under Medicare goes to a hospital and is only under observation, Medicare will not cover the full cost. So a viewer reached out to KSFY News reporter Vanessa Gomez about what it takes to be admitted, and she found out in this week's "Have you ever wondered..."
Medicare defines being admitted as an inpatient. A patient under observation is called an outpatient.
"Observation is essentially an outpatient, meaning the patient may not qualify for full inpatient coverage," Angela McCarvel said, who is the senior director of patient access management at Sanford.
She said the Centers for Medicare and Medicaid services, also known as CMS, require hospitals nationally to notify the patient they are classified as outpatient. Sanford complies with this by issuing the Medicare Outpatient Observation Notice within 24 hours of being under observation explaining why.
"We provide education to our patients, so they fully understand what we are classifying that patient as," McCarvel said.
On the MOON document, the list at the top defines why a patient wouldn't be admitted. McCarvel said sometimes CMS takes it on a case-by-case basis though.
"We may send something to Medicare as an inpatient, and it may not meet the qualifications based on what they interpret their guidelines to be," McCarvel said.
Sanford refers patients to the SHIINE program to give them more education on Medicare if necessary. SHIINE stands for Senior Health Information and Insurance Education program. Jeff Stingley said his office doesn't get many questions about being admitted or under observation. It mainly helps when patients are just starting on Medicare.
"Most people do not know about Medicare, and they've never had any reason to know about it," Stingley said.
Stingely said volunteers at SHIINE provide unbiased information for free to patients across South Dakota.
"Totally different ballgame within Medicare," he said. "If you don't do things right, you can get penalized for the rest of your life. Or you lose out on some pretty significant options."
In 2017, Stingley said SHIINE helped save Medicare patients more than $5 million. SHIINE has offices in Pierre, Rapid City and Sioux Falls.