At some point
you will be asked about Medicare, what is covered, what is not. As a nurse, you may not have to know the
details of Medicare, but it can prove to be beneficial. If a patient has been
instructed to undergo a test or procedure, they may question you as their
nurse, asking about Medicare paying for the test. It helps to have some information regarding
this complex and controversial program.
Medicare Basics
Medicare is a
government program designed to help cover some medical costs for older Americans. It covers more than senior citizens in
certain exceptions, for instance, if an individual is legally considered
disabled, they will at some point be eligible for Medicare. The cost of Medicare is just over $100 a
month, and in certain situations that cost may be offset by a state's low
income program.
Related: What does an RN Do?
Advocating for Patients
Hospitals
differ on how they handle obtaining authorization for patients to remain
hospitalized. Some have a designated
nurse to speak with insurance carriers regarding all patient care, including
Medicare patients. Other companies leave
it to the nurse that cares directly for the patient, in these cases if it is
your patient, you must speak with the company providing medical coverage for
the patient. There may be times your
role moves away from nursing and more into an advocacy role for the patient. It's important to have proper advocacy training,
or the patient could suffer.
Medicare and Advocacy
Here is an
example situation:
A 64 year old
female was admitted to the hospital with pain in her abdomen. After multiple tests, it was determined a
portion of her intestines were destroyed, possibly from a blood clot. The patient underwent surgery and began the
healing process while hospitalized. This
was not laparoscopic surgery, so there was some extensive recovery to take
place. After 6 days the patient was
suffering from severe diarrhea. Because
her surgical procedure was considered doing well, the Medicare representative
suggested the patient be discharged. The
nurse caring for the patient had never encountered the situation of advocating
for the patient to remain hospitalized, so when Medicare pushed for her
release, the nurse advised the patient she would be released. The nurse expressed concerns to other nurses,
but without realizing she could essentially argue for the patient to remain
hospitalized, she provided home care instructions and the patient was
released. 3 days later the patient was
readmitted, and spent 3 weeks in ICU.
She suffered from severe dehydration among other complications, that
according to the physicians could have been avoided had she not been released
so quickly. It is indeed the physician
that signs the release, but much of this decision is based on the tending
Nurse's evaluation. In this case, it
would have most likely been beneficial for the nurse to at least propose to the
Medicare official that the patient remain hospitalized until her severe
diarrhea was under control. The nurse
learned a valuable lesson in being a patient advocate, and thankfully the
patient did go on to recover.
Personalities
differ, and some people do not like confrontation, of course nurses are no
exception. If you happen to fall into
the category of not feeling comfortable debating patient care with any
insurance carrier, including Medicare, you may need some training in this area. There are courses and classes that
specifically instruct on advocating for patients. The proper training can build confidence and
ensure your level of comfort in advocating for patients is adequate to speak on
the patient's behalf.
Speaking with a Medicare Representative
Prior
to conversing with Medicare, arrange all pertinent information on the patient
so that it is at your fingertips. It may be helpful to avoid terms such as:
- I think
- I feel
- The patient has expressed
- The family has requested
Medicare puts
those terms into an elective category.
Instead, opt for terms such as:
- The patient’s vitals support
- My documentation indicates
- The patient is unable to
- Avoid entering the family into the conversation at all. Medicare views family involvement as support for the patient, and may be less like to approve additional hospital time.
Of course,
this is entirely dependent on individual experience.
There is no question,
a nurse is more than a provider of medical care, and being an advocate for your
patient is yet another important role nurses assume. Hospitals have an administrative staff that
can offer advocacy advice and work as a liaison between nurse, patient, and
Medicare.
Take advantage
of any training sessions aimed toward patient care with advocacy. The last thing to consider with Medicare is
to always follow up. If you don't
receive the answer anticipated, call back. The next Medicare representative may
have a completely different response.
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