investigations

Patients Caught in the Middle of Medicare

Thursday, Jun 5, 2014  • Updated 11:21 PM EDT
Patients Caught in the Middle of Medicare Getty Images

Every day is a battle for Dorothy Coggins, even with her daughter Patty by her side. But her bout isn't only physical.

It started in late April when Dorothy had back surgery at Backus Hospital in Norwich. Patty brought her there on a Tuesday morning and says the surgeon laid out a clear plan.

"She'll be in the hospital probably until Friday, and we'll move her to rehab as discussed. At 81 years old, there'll be no question," recalls Patty Russell.

The surgery went forward, but after three nights in the hospital the family received some unwelcome news the rehab center. They told Patty her mother's stay wasn't going to be covered because she was never admitted to the hospital.

Dorothy was technically "under observation" and had never achieved in-patient status, which is required for Medicare to cover any post-operative rehab care.

"We were told ultimately it's the doctor who was the only person who could turn this around," says Russell.

The reached out to the surgeon who confirmed the convalescent would not be covered.

Dorothy wasn't strong enough to return home, so they paid for rehab out of pocket, by writing a check for $4,970.

The they turned to Congressman Joe Courtney who has been working for years to address Dorothy's very dilemma.

"It's something that absolutely defies common sense when people find out that their coding situation treats them differently," said the Second District Democrat.

Medicare's auditing program was launched in 2008 to protect the system from improper payments. Cases like Dorothy's are the unintended effect, and they're becoming more and more common.

Courtney says last year, the inspector general for Medicare determined that there were more than 600 thousand cases of patients who'd been in the hospital longer than three days who fell into this gap.

Those in the medical profession say it's not a simple issue because both patients and providers of care are caught in the middle.

Doctor Steven Hanks, Vice President of Medical Affairs of Hartford Healthcare, the parent company of Backus Hospital, calls the system unfair. He says the Medicare audit system has physicians focusing on codes and categories and at the core is the almighty dollar.

"There's enormous pressure to reduce the spend, and when we look at spending, hospital care is a big chunk of what medical outlays are," said Hanks.

Congressman Courtney introduced House Bill 1179 last year to ease patients' access to Medicare coverage. The legislation says any patient in hospital for 3 days, would qualify for coverage of any post-hospital extended rehab or skilled nursing care.

The measure has nearly 150 co-sponsors on the Capitol Hill from both sides of the aisle, but Dr. Hanks believes the legislative solution is fraught with problems.

"It creates a perverse incentive in some ways to admit patients to the hospital to qualify them for that level of care," said Hanks. "Are we going to see a flood of 3 day admissions to hospitals in order to qualify with nursing care?"

Dorothy Coggins is back home with her daughter and son in law and is managing better every day. In the meantime, the family is still fighting to recover the thousands they spent on her rehab.

On June 2, the family received a letter from Backus Hospital in response to their complaints. It reads in part, "We follow the standards established by the federal government through the centers for Medicare and Medicaid services (CMS). If we establish an "inpatient" admission which does not meet CMS' standards, it is considered Medicare fraud. As a hospital, our hands are tied as well."

So while the frustration lingers, Patty is thankful that she can care for her mom, but she fears for the patient who doesn't have that some family support.

"I'm exhausted. I don't have the fight, so I can't imagine a lone senior citizen trying to do this," said Russell.

The NBC Connecticut Troubleshooters reached out to Dorothy's surgeon several times over the past two weeks via telephone and did not hear back from him.