Caution: Hospital “Outpatient” Rule Negates Statutory Inpatient Coverage for In-Hospital Dental CarePosted in Article
Medicare generally does not cover dental care (see 42 U.S.C. § 1395y(a)(12)). Under the law, however, if dental treatment must be performed in a hospital, either because of a patient’s underlying condition or the severity of the dental procedure, Medicare Part A covers the costs of the inpatient hospitalization, even if the procedure itself is not covered. For instance, Medicare payment would be made for the room and board, anesthesia, and x-rays, but not the fees for the dentist and other physicians (e.g., anesthesiologist and radiologist). Unfortunately, although beneficiaries are legally entitled to this coverage, it has been effectively negated by Medicare’s current outpatient “Two-Midnight” rule for hospital stays.
Implemented in 2013, the “Two-Midnight” rule states that hospital stays that are not expected to cross two midnights should be billed to Medicare as “outpatient” under Part B rather than “inpatient” under Part A. Because beneficiaries who must undergo dental treatments in a hospital typically stay there no more than several hours, they are not admitted as “inpatients” under this rule. As a result, their hospitalization costs are no longer billed to and covered by Medicare Part A. Patients and their families may be shocked by the unexpected hospital bill they must foot, on top of the fees for the dental treatment.
Case Study Demonstrates Harm
Recently, an Iowa resident (“Mrs. H”) contacted the Center for Medicare Advocacy regarding this very problem. Her husband (“Mr. H”), age 80, has been non-ambulatory for past two years after successive hospitalizations for major sepsis. Multiple spinal surgeries left him unable to move his neck. He requires a Hoyer lift for bed to wheelchair transfers. For many years, he was prescribed medications (i.e., Actonel, Fosamax, Prolia) to treat severe osteoporosis. A known side effect of these drugs is “osteonecrosis” (bone death) of the jaw, and associated dental problems.
This year, a dentist examined Mr. H in his wheelchair and found that his teeth were severely infected and needed to come out as soon as possible to avoid more sepsis. It was urgent, as Mr. H was already beginning to display agitation and combativeness, likely from the oral infection. Neither that dentist nor any of the oral surgeons’ offices or day surgery clinics in and around the city had a Hoyer lift to move him from his wheelchair to an operating surface. Mr. H also had orthopedic hardware, cardiac stents, a suprapubic catheter, and an oxygen concentrator for his pulmonary disease, which likely also presented a concern for these providers.
In the end, Mr. H had no option but to have his full mouth extractions performed at a hospital. His wife understood that Medicare would not pay for the extractions themselves, but had expected that the hospitalization costs would at least be covered, based on the plain language of the statute. She was not aware that this coverage would not be available to him because of the Two Midnight rule. As the hospital would not admit Mr. H as an “inpatient” and submit a claim to Medicare Part A under this rule, Mr. H would be liable for nearly the entire cost of having his teeth pulled in the hospital. He received a bill for close to $14,000, which he and his wife simply cannot afford.
December 12, 2019 – W. Kwok