What to Expect: A Guide to the Unexpected Medical Emergency

It’s a topic no one likes to think about: what happens when the unexpected happens. It’s just a regular day, you’re going about your regular business and you get a call: a loved one is suddenly — and urgently — seriously ill or injured. It might be a heart attack, a stroke, even a car accident. But in an instant, your lives are changed forever. When you or a loved one find yourselves’ in the middle of a medical emergency, it’s difficult to know what to expect. Of course, first and foremost on your mind is the patient’s well-being: will they recover? What’s the long-term impact of this experience on their life? But — prepared or not — these situations force challenging questions on you, questions that need to be answered quickly:

  • Who decides on the patient’s treatment plan?
  • Where will your loved one go after this hospital?
  • How will you handle the unexpected expenses?
  • How will you and your loved one adjust aftercare?

Understanding the areas that you might be responsible for managing before an emergency health care situation strikes will help you make better, more informed decisions. That’s where Amazing Healthcare Consultants can help. From managing care in the hospital and understanding the discharge process to readjusting to normal life after care, we can help. From the time your loved one is settled in a hospital room (and out of the ICU) to returning to a “new” normal, this Guide will help you make smoother transitions in an anything-but-smooth time.

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AHC Unexpected Medical Emergency Guide Infographic

Concern #1: How to manage care in the hospital?

Who’s in charge? A Guide to Health Care Directives

If your loved one is in the hospital and unable to make decisions for themselves, you need to know what — if any — legal direction they’ve left for others to make decisions for them. These legal directions, called Health Care Directives, allow patients to inform medical professionals and family members about what kind of care they want when they can’t communicate those wishes for themselves. The names for these documents depend on the state in which you live, but they each create the opportunity to provide instructions about the type of health care a patient wants to receive.

Legal TermAlso Known AsDefinition
Durable Power of Attorney for Health Care
  • Medical Power of Attorney
  • Power of Attorney for Health Care
  • Designation of Surrogate
  • Patient Advocate Designation
A legal document in which you give another party permission to make medical decisions for you if you are unable to make those decisions yourself.
Living Will
  • Health Care Declaration
  • Directive to Physicians
  • Health Care Directive
  • Medical Directive
A legal document in which you state your wishes about life support and other kinds of medical treatments. The document takes effect if you can’t communicate your own health care wishes.
Advanced Health Care DirectiveN/AThis term usually refers to a single legal document that includes both a health care declaration and a durable power of attorney for health care. It is currently used in more than one-third of the states. Technically, however, both living wills and durable powers of attorney for health care are types of advanced health care directives.
Health Care Agent
  • Attorney-in-Fact for Health Care
  • Patient Advocate
  • Health Care Proxy
  • Surrogate
  • Health Care Representative
The person you name in your durable power of attorney for health care to make medical decisions for you if you cannot make them yourself.

What happens if there isn’t a healthcare directive in place?

If your loved one does not have an advanced directive is in place, the party responsible for care decisions varies from state to state. Generally, a doctor or hospital will accept a spouse or child as an informal decision-maker. In some situations, a family member has some role by law. At other times, a guardianship proceeding will have to be initiated in probate court. AHC can ensure that you and your family have all of the proper precautions in place to guarantee your loved one receives the care they need, regardless of the decision maker.

What do I do if we want to change hospitals?

If you decide that a different hospital would be a better facility, either for proximity to loved ones or personal preference, the main factor lies with the insurance company. When considering change, be sure to pre-authorize the new facility to ensure that it is covered. Often time, the odds of changing hospitals and retaining coverage is low.

Concern #2: How does hospital discharge work?

Moving Forward

Hospitalizations have become an accelerated process and are becoming shorter every year. Because a patient discharge doesn’t necessarily occur when you are completely healed, but rather when you are at a point where care is less expensive at a secondary location, like a rehab hospital or your home. As a caregiver, your primary focus is getting your loved one the care they need. Whether the discharge is to a rehabilitation hospital or an assisted care facility, a smooth transition is critical to the health and well-being of your loved one.

Leaving the Hospital

In a perfect world, hospital discharge would take place when you, your loved one and your doctor think the time is right. However, opinions may vary on whether or not a hospital discharge is the right course of action. Remember, discharge decisions will depend greatly on your loved one’s condition, as evaluated by your attending physician or care team in the hospital.

AMAZING TIP! Know your rights as a patient!

Health Insurance Providers Decide Paid Stay Length

To determine what the insurance company will pay for, payers rely on diagnostic codes, called ICD codes, and procedure (service) codes called CPT codes to describe the services provided. Those descriptions determine the average amount of time the patient is approved to be in the hospital to complete the tasks that fall under those codes. Once the time is up, the insurance company (private insurance or Medicare) will no longer pay for the patient’s stay. If the insurance company does not pay, and there are no other payment methods, the hospital can defer the remaining balance to the patient.

What you need to know about Discharge Against Medical Advice (DAMA).

Questions to Ask Before Leaving the Hospital

Caregiver involvement in the discharge process is very important. Deciding to leave is a complicated decision, and all options must be carefully evaluated by all parties. Remember, the goal is to ensure the patient has a safe, healthy path to recovery. As the caregiver, it is your job to ask the right questions and get the information you need before you go out the door. Here are a few questions to ask your hospital discharge planner or primary care doctor:

Personal Care

  • Will we need help with dressing or bathing?
  • Will we need help with cooking and housework?
  • Will my loved one be safe at home upon discharge or will someone need to be with them 24 hours a day?

Medication and Therapy

  • What therapies will be required?
  • What does each medicine do and why is it needed?
  • What are the medication dosages, interactions, and side effects?
  • Who do we call if we have questions about medical equipment such as oxygen or a walker?
  • What is the average length of recovery time?

Symptoms and Side Effects

  • What problems, symptoms and side effects should we watch for?
  • What should we do about any potential side effects or problems?
  • Who do we call for emergencies?

Care Costs

  • What services will health insurance or Medicare pay for?

Concern #3: Where do I go after hospital care?

After an acute care stay at the hospital, many people will need rehabilitation services, such as occupational therapy, physical therapy, speech therapy or at-home nursing care until they are fully recuperated. Often, families are not aware that there are choices regarding where to complete rehabilitation. Hospitals may recommend a post-care facility, but your loved one is not required to go there. Determining the best post-acute care location depends on your family situation, personal preference and area availability. Getting a second opinion on a post-acute setting is recommended.

AMAZING TIP! Do not wait until the last second to choose your next move! Upon learning that a secondary facility might be needed, start thinking about next steps! Rehabilitation is usually conducted at a secondary facility, such as at a rehabilitation hospital, skilled nursing facility, or patient home. In most cases, the most important factor in determining where to complete rehabilitation is to find a setting that will reduce their risk of hospital readmission while helping the patient regain strength and confidence as quickly and safely as possible. If you still find yourself needing more time to make a decision, AHC has the insurance policy knowledge necessary to help extend your stay time at a hospital. Next, we’ll discuss a few of the options for post-acute care settings.

Skilled Nursing Facilities (SNF)

If you or your loved one requires extensive nursing services, or is confined to a bed, an SNF is the best option. Skilled nursing facilities are for patients who require 24-hour nursing services and skilled medical care. Many SNFs are often set up like hospitals — with similar room arrangements.

Rehabilitation Hospitals

Rehabilitation hospitals are devoted to the post-care rehabilitation of patients with various neurological, musculoskeletal, orthopedic and other medical conditions following stabilization of their acute medical issues. In short, rehabilitation hospitals were created to provide stabilized patients a higher level of professional therapies — specifically physical therapy — with less focus on emergent medical needs. When it comes to rehabilitation after illness or injury, acute care rehabilitation hospitals tend to hold a clear advantage over other settings. Research shows that outcomes are better and recovery is faster in a rehab hospital, compared to a skilled nursing facility. This advantage is mostly due to the timely, intensive and coordinated programs provided in a rehabilitation hospital.

Rehabilitation Care at Assisted Living

Many seniors complete their post-acute care at an assisted living community, even for a short-term stay. Similar to home health services, rehabilitation care at assisted living facilities can provide specific therapies and 24-hour medical services to the patients (which are sometimes covered by Medicare)*. Some assisted living communities even offer on-site occupational and physical therapy rooms, giving patients access to high-tech equipment multiple times throughout the week. *Medicare has specific guidelines regarding PT/OT and Speech Therapy. Medicare will cover only qualified healthcare covered cost while a patient is in these facilities. Generally, if your loved will require help with daily activities such as getting dressed, meal preparation or bathing, assisted living might be a good rehabilitation option. However, not all assisted care facilities have to be a long-term solution for patients. For those who expect to go home after a period of rehabilitation, a short-term respite care stay, which typically lasts less than two months, might be a good option. If you are unsure whether or not a respite care plan is the right choice, here are a few things to think about before making a decision.

Respite Care Plan Decision Factors

If…Yes/No
Your loved one does not need therapy, but lacks the confidence to go home, assisted living might be a good option - especially with support 24 hours a day.
Family is unable to assist with providing help at home due to location restraints or relationship challenges.
Your loved one has experienced multiple hospitalizations or is at risk to be re-hospitalized – especially if there is uncertainty in at-home care being a safe, long term option.
Your loved one or family values complete peace of mind. Even if the care is short term, having comfort in knowing that their loved one is being cared for 24 hours a day is a great relief.

AMAZING TIP! If you answered “Yes” to 2 or more of these conditions, talk with your physician about rehabilitation at assisted living. Keep in mind, post-acute care treatment and planning can vary greatly from patient to patient. Often time, choosing to approach the rehabilitation with pre-planned steps yields better results. Respite stays at care facilities are often a gradual, less abrupt change into post-acute care living.

In-Home Care

Sometimes, a patient is ready to go home but still requires medical help, or help with daily living activities. These services are provided through home care, and home health services, although there is often confusion on the difference between them.

Home CareHome Health Services
DescriptionHome care is non-medical support, where the duration of care is specified by you or your care partner.Home health services are provided by licensed medical professionals who come to the home to do a specific task that has been ordered by a physician.
Paid for by insurance or Medicare?NoYes
Typical Activities
  • Cooking
  • Cleaning
  • Running errands
  • Laundry
  • Delivering medications
  • Checking vitals
  • Administer injections
  • Provide wound care
  • Therapy Exercises

Is it possible to need both home care and home health service? The answer is “yes,” depending on your circumstances.

Post-Care Facility Insurance Coverage At-a-Glance

FacilityCovered by Medicare?Covered by Medicaid?Covered by Private Insurance?
In-Home CareXX
SNFXXX
Rehab HospitalXXX
Assisted LivingXXX

*Insurance coverage and costs depends on selected plan

Is 100 Days of Care Enough? For Medicare, up to 100 days are covered when staying in a SNF or Rehab Hospital — see full requirements here. Days covered will vary on private insurance plans. While 100 days of recovery may seem like a long time, stay length can vary depending on the health condition. For example, patients recovering from a heart attack can expect to be sent home in around 5 days, depending on the severity. However, patients recovering from a stroke could be in rehabilitation anywhere from a couple weeks to several months. Average Stay Length

IssueRehabilitation Facility PatientSNF Resident
Average length of stay in post-acute care for all clinical categories12.4 Days26.4 Days

*Data obtained here

Curious if your care will be covered by Medicare? Check out our Medicare Guide!

Concern #4 - How will I pay for my care?

In a midst of a medical crisis, caring for your loved one is priority number one. But sometimes without realizing it, medical bills can start to pile up. From helping you manage the inflow of bills and paperwork, to helping you understand what you’re being billed for and why, AHC can help.

What will my insurance cover?

In short, coverage for care will vary greatly depending on your plan. In general, all qualified plans have to cover the same set of essential health benefits. Bolded items represent services that might be used more frequently if your loved one is in an emergency medical situation.

Essential Benefits

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity, and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices(services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

If you have Medicaid, Medicare or a plan through the federal marketplace, prepare for the billing in the following weeks.

For more information on open enrollment, coverage options and cost, check out our Amazing Guide on Open Enrollment.

What happens if I can’t afford my bill?

Medical debt was responsible for 62 percent of personal bankruptcies in 2007, according to a recent study, which also found that most medical debtors were well-educated and middle class, and three quarters of them had health insurance.

A National Health Interview Survey found:

  • 1 in 3 persons was in a family experiencing financial burden of medical care
  • 1 in 5 was in a family having problems paying medical bills
  • 1 in 4 was in a family paying medical bills over time
  • 1 in 10 was in a family that had medical bills they were unable to pay at all.

Unpaid medical bills can damage your credit score, making it difficult to take out a mortgage, buy a car, rent an apartment or even land a job. While unplanned medical incidents can have a negative impact in many areas of you or your loved one’s life, finances CAN be controlled. If you can’t pay a medical bill, or pay for a service upfront, see the steps below.

    1. Read the details and check for errors. A large proportion of medical bills contain clerical errors that result in overcharges. Anywhere between 50-80% of medical bills contain errors. If you notice that you’ve been wrongly charged, call the insurance company and have it corrected. Often time, the medical provider will be willing to work with you to avoid going through collections. Many people don’t realize that medical bills can be negotiated – both through the health care provider and the insurance company. It is recommended to keep copies of your own medical records for cross-comparison with the insurance payer’s bill.
    2. Ask for assistance. If you’re living at or below the poverty line, ask your doctor’s office or hospital about assistance programs. Many local and national charities offer medical billing assistance, and the medical providers themselves may waive part or all of your fees if you’re in dire straits financially. If you’re within the eligible income range for Medicaid, apply as soon as possible. Often, government-funded programs will back pay outstanding medical bills once you’re signed up.
    3. Don’t ignore the bill. Unpaid medical bills are a huge problem for many Americans. In fact, medical bills are the leading cause of personal bankruptcy in the United States today. While it is undoubtedly a stressful time, help is available. Chapter 13 is not the only option. Additionally, once that bill goes to collections, you lose some of your bargaining power.

The Billing Process

Medical billing might seem intimidating and complicated, but the process can be broken down into a few steps: registration, patient check-in and check-out, claim preparation and transmission, payer adjudication, generating patient statements or bills, and assigning patient payments and arranging collections. While the intricate details of the process aren’t crucial to know, having a solid foundation of knowledge will better help you break down and understand your health bills. NOTE: In most cases, the “payer” is the insurance company. NOTE: In most cases, the “payer” is the insurance company.

  1. Registration When patients call to set up an appointment with their healthcare provider, they essentially pre-register for the visit. If it is a return patient, they simply have to state the reason for their visit as their information is already on file with the provider. If it is a new patient, personal and insurance information must be provided to the healthcare provider to ensure that they are eligible to receive services.
  2. Patient Check-in and Check-out During check-in, new patients will often be asked to complete forms. If it is a returning patient, information confirmation is required – such as current home address or phone number. During check-out, the provider’s office will collect copayments. Although the provider can determine whether copayments are collected during the check-in or check-out process. After the patient checks out, the medical report is sent to the medical coder. In short, the medical coder translates the report into an accurate, billable medical code. Once the superbill is generated, it is sent to the medical biller. A superbill is an itemized form used by healthcare providers for reflecting rendered services. AMAZING TIP! Copayments will always be collected at the point of service.
  3. Prepare Claims The medical biller will take the superbill and either put into a paper-form claim, or into the proper billing software. Cost of procedures in the claim are also added during this time. After the medical bill is reviewed for compliance, the biller will send an amount to the payer to be paid.
  4. Adjudication Once a claim reaches a payer, the adjudication process starts. The payer will evaluate the medical claim and it’s validity. If it is valid, the payer decides how much is reimbursed to the provider. Once the adjudication is complete, the payer sends a report to the provider/biller. Finally, the biller will review the report to ensure procedure and claim accuracy.
  5. Generate Patient Statements Once the biller has received the report from the payer, it’s time to make the statement for the patient. The statement is the bill for the procedure or procedures the patient received from the provider. After the payer has agreed to pay the provider for the procedure(s), the remaining amount is passed on to the patient.
  6. Patient Payment Follow-Up The last step in the billing process is ensuring that the bills get paid. Billers must send the bills out in a timely manner, ensure their accuracy and then follow up with delinquencies. Each provider has its own set of guidelines and timelines when it comes to bill payment, notifications, and collections. It is recommended to refer to the provider’s billing standards during the payment period.

Keeping Track of Your Medical Bills

No matter the situation, after a medical emergency, there will be an influx of bills. It may seem overwhelming, but managing the incoming paperwork and organizing it will make your life much easier in the future. Here are a few tips on how to successfully track and manage incoming medical bills.

The Medical Bill and the EOB

After receiving care from your doctor or hospital, you can expect two important documents in the mail. First, the actual medical bill. This will come from the provider of care, such as the hospital, clinic, or laboratory. Second, you will receive the explanation of benefits, or EOB. The EOB explains the discounts to you. It will also show the amount you owe. If your provider didn’t send you an itemized statement, it would be wise to request one. EOB’s will always come from the insurance company or Medicare. AMAZING TIP! The EOB allows you to compare charges to the bill, making it easier to spot mistakes and track expenses.

Tips For Organization

    • Create a calendar showing all your medical appointments. Add notes with the name of the provider and the type of care provided. This way, you’ll know when and from whom you should be expecting bills and EOBs.
    • Organize medical bills and EOBs by the date that you received care, but note when the bill and EOB was received as well.
    • Keep track of the dates you paid each bill! It is also a good idea to make hard-copies of the check or credit card receipt of each payment.
    • When paying bills, be sure to have a copy of your current insurance benefits and/or health care plan description on hand for quick reference.

Concern #5: Readjusting Back to Normal Life

Sooner or later, your loved one will be sent back home. A new injury may have thrust you and your family into a new normal – one that requires a higher level of attention and care. But, readjusting back to a routine is crucial in continued positive patient outcomes. Going back to work, enjoying hobbies and reestablishing relationships are all part of a road that leads to a strong recovery.

Going Back to Work

For most, working is a part of life. That can all change if you or a loved one has a sudden serious injury. Moving forward after an injury many question how should returning to work be handled. To what extent can, or should, your loved one return to work?

Do I Qualify for SSDI?

Social Security Disability Insurance (SSDI) is a Social Security program that pays monthly benefits to you if you become disabled before you reach retirement age and aren’t able to work. To qualify, you must have worked a certain number of years in a job where you paid Social Security (FICA) taxes. Specifically, you need to have earned a certain number of work credits; you can earn up to four work credits per year. For more information, or to see if you qualify..

Am I covered under the ADA?

The Americans with Disabilities Act (ADA) prohibits discrimination on the basis of disability in several critical areas. Those areas include state and local government services, places of public accommodation, employment, telecommunications, and transportation. Under the ADA, you have a disability if you have at least one of the following:

  • A physical or mental impairment that substantially limits one or more major life activities
  • A record of such an impairment
  • You are regarded as having such an impairment.

See a more complete list of conditions that are covered or not covered..

Family Adjustments

One of the most important factors in a patient’s recovery after a disability, injury or illness is the involvement and support of the family. Positive attitudes and reinforcement from family members can encourage patients’ commitment to recovery and help them adapt to their new set of challenges. Family support and encouragement can also help patients deal with issues of self esteem related to their condition. Roles and responsibilities may shift from what they used to be. For example, a family member may need to rearrange their work schedule, decrease their hours, or even take a leave of absence to manage his or her caregiver responsibilities. There may be a change in living arrangements, issues that arise with childcare, financial problems due to medical bills or unemployment that contribute to pressures on the family. Curious if you qualify for the Family Medical Leave Act (FMLA)?. There are several ways that you as a family member can ease the day-to-day stress of caregiving:

  1. Ask other family members and friends for assistance. It helps to make a list of all the caregiving tasks required, and then determine which activities you can accomplish on your own and which ones you might need a hand with.
  2. Make it a priority to regularly meet with friends and do things you enjoy. By doing the things you love you’ll feel more energized and better able to care of your loved one.
  3. Exercise regularly, eat right, get enough sleepand keep up with regularly scheduled doctor’s appointments. Taking care of yourself is crucial.

The important thing to remember is that you are not alone. Help exists for those who ask for it. By working together with the rehabilitation team, the patient and family can help reduce the adverse outcomes of this new normal and work toward finding realistic, mutually beneficial solutions.

CONCLUSION

    We hope this guide was able to help you manage care in the hospital, understand bills, adjust to normal life and everything in between. Amazing Healthcare Consultants strive to make your life in the medical world easier.

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