Real World Claims Denial

Your Dad gets admitted to the hospital with “…Chest pain.  His medical history included an elevated Blood Pressure.”  The hospital admits him overnight for observation and Medicare refuses to pay the hospital.  Surprised?  Don’t be.

This is real life, and its my Dad, last August.  Today in the mail I was cc’d on his appeal with Maximus, the Medicare Appeal Firm.  Here is why they declined the claim:

“His cardiac enzymes remained negative and his symptoms resolved.  His hospital course remained uneventful and he was discharged to home the next day in stable condition.”

Then they say “The overnight observation and treatment could have been safely managed at an observation level of care, a less intensive setting than inpatient designation.  If during that period of observation a significant change in his condition occurred that would have required more intensive services, he could have been transitioned to inpatient status.”

Reeves Translation – you should have left him in the Emergency Department, in a hall bed overnight.  If something happened then you could have been paid, but we are not paying you for your cautious patient-oriented approach.”


What do you think?