Here is the Problem


ERP here again while WC recovers from the revelling in Boston

Personally, I agree with medicare and insurance regulations that require that someone receive some REAL benefit in order to be covered for an admission to the hospital. Even the “social dispo” admits usually serve a purpose – preventing elderly or the otherwise helpless or nearly helpless from injuring themselves or insuring they get proper medical treatment like antibiotics or seizure medications. However, if you can be safely discharged from a medical AND social point of view (ie no admit-able diagnosis exists AND you can either care for yourself or someone is there to care of you (like in a nursing home), you should have to pay out of pocket if you (or your relative) demand you be admitted. You can’t just come in for “tests” or to see a “specialist” or to “recuperate”. I am sorry, if you are demanding and non-indicated admission, prepare to ante up.

The other day I had several situations where elderly, demented, bedridden, and or chronically ill elderly people from nursing homes were admitted solely because the entitled relatives refused to allow them to be transported back to the home. They had no acute diagnoses requiring admission but their relatives had such a fit that the PMD’s acquiesced and admitted them. Now, the hospital has to try to recoup payment from medicare. This is an epic waste of resources and public health care dollars.

Here is what I did. I documented that the patients had NO indication for admission and recommended the patient (ie family) be charged fully for the admission, thus destroying the hospital’s ability to bill medicare. My hope is that the hospital not even try for medicare reimbursement and instead submit their entire bill to the entitled family, and if they refuse to pay, send them to collections. Hopefully they will learn that there is no free medicare lunch. Who knows, maybe the hospital will reprimand me. Regardless, I had to do it.


  1. I completely agree with this:

    “I documented that the patients had NO indication for admission”

    You run risk with this:
    “and recommended the patient (ie family) be charged fully for the admission”

    Not because it’s wrong, but because it sounds prejudicial and if this lady winds up dying (which happens from time to time — they are old, they get sick, etc) then comments like this will make it easy for the plaintiff’s attorney/Medicare QIO/Hospital RM Committee to depict you as a hostile/uncaring/punitive doctor who clearly was so preoccupied with money that you just missed the obvious diagnosis.

    It’s also unnecessary. Dictate that there’s no indication for acute hospitalization, recommend “Observation” status, and the coders/utilization review folks will take care of the rest.

  2. I agree wholeheartedly with you, the ones that we have a hard time with are those where the relatives come in claiming a the elderly patient had a new syncopal attack (of course the pateint doesn’t remember it, must be part of the syncope!) or someother complaint like severe chest pain that the patient doesn’t remember. Anyway, they have learned to work the system so we end up admitting them!

  3. I’ve seen this work in the prehospital arena; not as a punishment, but as a way of explaining things to patients and family.

    [EMT] Ma’am, your child has no apparent life-threatening medical problems, and the hospital is only a block away. Are you sure you want to us to take you?

    [Mom] Nothing but the best for my baby! Give us an ambulance ride!

    [EMT] I’ll be happy to, but I want to make sure you understand that Medicaid won’t cover it and you will be responsible for the bill.

    [Mom] Nothing but the best for my baby! Give us an ambulance ride!

    [EMT] It’s $500 plus $15/mile.

    [Mom] I’ll get my car keys.

    This could be equally effective with patients who can’t/won’t understand the more complex decisions involved in hospital admission.

    • I remember my old prehospital day’s… and even now working in the ER where I’ve been told “so? I don’t have to pay for it!” Since there is no up front billing.. folks are going to do it and not worry about it. Unfortunately, there’s not a lot that can be done about it.

  4. Just an FYI — the family won’t be responsible for the bill unless they signed something agreeing to such a situation. The hospital will merely be unable to collect anything unless the patient has financial resources.

    • Yeah, not much of a punishment unless she dies with assets and you collect from the estate. ERP cut off his own nose on this one most likely.

  5. Completely agree. If patients had more skin in the game, they’d control costs themselves. You want an MRI when standard of care is to get physical therapy instead? Fine, that will cost you $3000. An ED visit will cost you $300 when your PCP will see you for $50? Easy choice. This is why handouts aren’t the answer.

  6. handouts ARE the answer as long as customer satisfaction surveys are tied to my pay and i have no (direct) financial disinsentive to block these admissions. give ’em what they want, admin is telling me.

  7. Actually, I did not write exactly “Patient should pay for the admission” – I wrote something more like what Shadowfax said, in no uncertain terms that this was a requested (well, more like demanded), medically non-indicated admission for the family. On the diagnosis I wrote “Medically unnecessary admission – Family request”.
    That was as close to saying “Medicare should not reimburse for this”. Also Dan R, patients (or families) at our hospital sign a paper saying they will be responsible for the cost of admission (and ER treatment) if their insurance does not cover it.

      • Why not just admit this person to observation and let the hospital collect something for occupying the bed? The patient will get stuck with a huge bill for all them medications, and if something is wrong with the patient that you missed with your 5 minute ER consult, then it can be change to a regular admission later on and the hospital will collect even more money for the admission. I am not sure why you don’t want the hospital to loose out on the payment for the admission????

    • Why would a family sign such a waiver? I can understand the patient signing it, but why would I as a son of a patient accept liability for a debt that I have no legal obligation for? If the patient want’s admission, that’s fine. If the family want’s admission (esp if they have medical power of attorney) they can obligate the patient but not themselves.

      The end result being that unless the estate has resources (and most nursing home patients that I know don’t), then the hospital collects nothing.

      • People like you are the problem. you want to be able to DEMAND what you want but, you don’t want to be responsible for the cost. As much as I dislike Happy he’s right “the patient has to have some skin in the game”

      • If the family want’s admission (esp if they have medical power of attorney) they can obligate the patient but not themselves.”

        If the FAMILY demands an unecessary admission then the FAMILY should be obligated. Why should the family be allowed to obligate the patient when the patient isn’t the one making the demands?

  8. Pingback: Worthless Admission

  9. I had a situation different (and yet similar) the other day. I’m in Canada, so it’s a different game, of course.

    A patient was visiting from out-of-country and needed to be admitted. No travel insurance. The family member (covered by OHIP) was appalled at the cost of an inpatient admission for non-Canadian (about $3000/day for a medical bed) and felt that “it should be free for her…how can anyone afford that?”.

    Thing is, we Canadians are cheap -when you don’t have to “pay” for something up front, then ANY amount seems expensive. But most of us buy travel insurance when we leave our own country, so we have a hard time understanding people who complain about the cost of things when they enter our healthcare system, and who didn’t bother with any insurance of their own.

    No explanation worked -that ours is ‘free’ because we pay taxes, that she should have obtained travel insurance, that they could work out a payment plan with the hospital. They signed out AMA instead and told me they were flying her back home.

    I guess that’s one option.

  10. And, I STRONGLY agree with what you did. Families in these cases are a remarkable waste of resources. I deal with this crap. Alzheimer’s patient brought in because the family is worried he’s been getting worse over the last 3 years. And, of course, they want the whole damn work-up repeated.

  11. I am an emergency vet, so have to deal with irrational people all of the time (most in situations that they could have avoided if they had been following the”rules”). I have to fight for the opposite: PLEASE let me admit your polytrauma dog who has 40% of his face smeared across Main St. But people see the price for hospitalization (it runs around $300-500/day once diagnostics have been done). They are horrified and say something along the lines of “but it doesn’t cost *me* this much to stay in a hospital. Of course it doesn’t, it costs a hell of a lot more, but the rub is, you are more likely NOT to pay it…hoping that the government will do it.

    Personally, I have crappy insurance. Therefore, I pick and choose what diagnostics and procedures have to be done because of my high deductible. I cannot afford PT because it is $150/tx. I make about $300/week as a base pay (before 5 of production kicks in), so unless I want to really get behind the 8 ball, I cannot afford it.

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