Fact Check: Must over-75 patients be admitted to the hospital only by their primary care doctor in order for Medicare to pay?

April 19--Times-Union readers want to know:

Is it true that Obamacare changed hospital admittance rules to say that if you are over 75, you must be admitted by your primary physician in order for Medicare to pay for it? This email I received also says that if you are admitted by an emergency room doctor, it is treated as outpatient care and hospital costs are not covered.

There have been a rash of bogus emails and postings about Medicare and the Affordable Care Act.

This is one of them.

FactCheck.org queried the nonpartisan Center for Medicare Advocacy about this viral email. Policy attorney Andrea Callow responded in an email: "I can say without hesitation this is false."

Callow wrote that "nothing in the Affordable Care Act contains a requirement that a primary care physician admit a patient if they are 76 or older."

Medicare coverage for hospital care is based on the Social Security Act's criteria for Medicare Parts A and B, as well as rules and guidance from the Centers for Medicare & Medicaid Services.

"There is nothing about age or PCP [primary care physician] vs. ED [emergency department] doctor in the law that affects a beneficiary's Medicare coverage," Callow wrote.

In addition, a spokesman for the Centers for Medicare & Medicaid Services told FactCheck.org that "we know of no such provision in the ACA that required this."

The Medicare.gov website says that Medicare Part A covers hospital services when "a doctor makes an official order" instructing that you need inpatient hospital care for treatment. The website does not specify that it has to be your "primary care physician," as the email says.

In addition, as FactCheck.org points out, the Centers for Medicare and Medicaid Services, in its Jan. 30 guide on "Hospital Inpatient Admission Order and Certification," covers who can submit an order for inpatient services, as a condition of payment under Medicare Part A. Nowhere does it say that a primary care physician must make the order.

Callow told FactCheck.org that she thinks the viral email's claim stems from the concern about how Medicare bills patients classified as "outpatients" even though they stay overnight for "observation services."

We've covered that recently in another Fact Check column. If you are not officially admitted to the hospital as an inpatient by a physician, then you might be an "observational patient" and you are likely to pay more for hospital services.

This is a very real situation, unlike the over-75 admittance rule in the viral email.

The Centers for Medicare & Medicaid Services urges Medicare patients to clarify their status within hours of arriving at the hospital: "If you're in the hospital more than a few hours, always ask your doctor or the hospital staff if you're an inpatient or an outpatient," says a pamphlet issued by the CMMS.

Callow told FactCheck.org that her organization, Center for Medicare Advocacy, has followed this inpatient vs. observational patient issue since at least 2000. And it, she said, also has nothing to do with the Affordable Care Act, or which physician is responsible for admitting the patient.

Carole Fader: (904) 359-4635

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