Admission or Observation? What's the Difference?

It has been estimated that doctors can spend upwards of two-thirds of their time on paperwork. In the case of Dr. Jim Trumble, Medical Director of Physician Utilization for Frederick Memorial Hospital, that is often time well spent in support of his patients.

Dr. Trumble and the hospital’s case managers spend much of their time researching the latest recommendations, guidelines, and best practices supported by the nation’s leading medical associations and research institutions. These include the American College of Cardiology, the American Heart Association, the National Institutes of Health, and the Centers for Disease Control. They also closely follow federal and state insurance regulatory requirements.

All of these efforts are for the benefit of patients who may find that their insurance companies are questioning the decision to admit them to the hospital versus holding them for observation.

“To be clear, we provide great care regardless of whether a patient is admitted or held for observation,” Dr. Trumble explained. “The difference is in the severity of illness, how insurance coverage applies, and therefore what the patient will be required to pay.”

With nearly 20 years of experience as an emergency medicine physician, Dr. Trumble is well versed on admission standards for patients who present with symptoms of an obvious health emergency such as heart attack, stroke, or life-threatening injuries.

However, there are other times when the scenario is not so clear-cut. “In those cases, we are called upon to use our experience and knowledge to form an educated opinion as to what the patient’s course of treatment will be so that we can make decisions regarding whether they should be admitted to the hospital right away,” he said.

In most cases, when Dr. Trumble and his team reach the conclusion that a patient should be admitted, that decision is supported by insurance companies. There are times, however, when the insurance company may disagree.

That’s where having done his homework pays off and Dr. Trumble is able to help his patients.

“In those cases where the insurance company denies our recommendation for admission, I often refer to research I’ve read in publications, from the American College of Cardiology for instance, to say, ‘Well, in this particular case, there is precedent for admission,’” he said. “Usually, when presented with that kind of third-party, documented evidence, we are able to help insurers understand and agree with why we’ve recommended a particular course of treatment that calls for admission.”

Dr. Trumble also says that the hospital’s case managers can help patients understand the basics of Medicare and Medicaid coverage, and can guide patients with private insurance to resources that can help them better understand their own coverage. “Our primary goal is to make sure our patients return to good health,” he said. “But if we can help make that journey easier by providing help and resources, all the better.”

To learn more about when a hospital stay is not an admission, pick up our latest issue of Well Aware magazine or click here.