Booklet Gets Status Change Facts Wrong 

Some of you may know that each year, Medicare sends a book to each Medicare beneficiary, titled “Medicare & You.” This is the book that explains in detail the Medicare program, what is covered and not covered, and how much services will cost. It is the book that Medicare thinks every beneficiary carefully reads, so there will never be a question about coverage or benefits. Sadly, this is my third year receiving this booklet, and I decided to actually sit down with a cup of coffee to read it.

I did notice two things about the content that every case manager and physician advisor should know. First, there is a nice section about the Advance Beneficiary Notice explaining patient liability for certain services. But the booklet does not have one single mention about the Hospital Issued Notices of Non-Coverage. For that, you would have to go to the online version of the book and then click on a link. Why discuss financial liability for outpatient care and ignore the same for inpatient care? That’s not evident.

Then, there is a section that discusses observation care. It starts by stating in bold letters, “Important! Each day you have to stay, you or your caregiver should ask the hospital and/or your doctor, a hospital social worker, or a patient advocate if you’re an inpatient or outpatient.” It then notes that “sometimes doctors will keep you as an outpatient for observation services while they decide whether to admit you as an inpatient or release you” and then outlines the requirements for Medicare Outpatient Observation Notice (MOON) delivery.

It is gratifying to see the Centers for Medicare & Medicaid Services (CMS) call observation a service and not a status. But sadly, they ignore the crucial role of case managers by telling patients to “ask the hospital,” as if you could ask a building a question. And then CMS really goes off the rails. They note that “you have appeal rights when a hospital changes your status from inpatient to outpatient if you meet certain conditions. Go to page 105 for more information.”

As you could guess, I quickly turned to page 105, and found this statement: “you have the right to ask for a fast appeal while you’re still in the hospital if you were admitted to the hospital as an inpatient and the hospital changed your status to outpatient getting observation services.” That is followed by a long web link, which is of limited value in a paper booklet.

But to that link I went, and on that page I had to click another link and go to another page. And sadly, I was disappointed there, with no mention of the strict requirements to qualify to appeal a Condition Code 44 change and no mention of the delivery of the Medicare Change of Status Notice (MCSN).

As you would expect, I did my due diligence and searched my bookshelf for the 2026 book. And it had similar language, but also included the statement “you must meet certain requirements to appeal.”Why CMS left that crucial statement out of the 2027 booklet is unclear.

Will the absence of the “certain requirement” statement mean we will see more patients requesting an appeal of their Condition Code 44 change when one is not available because they have Part B or did not remain for three days after the change? It’s possible. That assumes that Medicare beneficiaries actually read the 128-page booklet, and don’t skip over that rather dull section.

And what should you do if you encounter a patient who did read the booklet, and wants to appeal their change to outpatient with observation services? First, of course, is to determine if they qualify for receipt of the MCSN. If so, hopefully they received it and know to call the Quality Improvement Organization (QIO) directly.

But for the patient who does not have formal appeal rights, I would allow them to call the QIO and ask for the appeal. Remember, every patient has the right to call the QIO and ask for help. Hopefully, the QIO will tell them they have no formal appeal rights, but the QIO should offer to review the situation through their informal immediate advocacy program.

But also remember that if their hospital care is complete and the patient insists upon staying to await immediate advocacy, you can issue an Advance Beneficiary Notice (ABN) for custodial care and charge them to remain hospitalized, as unlike the MCSN (or HINN 12), there is no protection from liability during the immediate advocacy interaction with the QIO.

Now, back to the booklet. I went to determine which Part B supplement I will want to purchase when I finally retire and lose my employer-sponsored insurance. I can only hope the information in the booklet is accurate.