Skip to main content

Suspension of Two-Midnight Rule Reviews Could Last Through July

News  |  By Christopher Cheney  
   June 08, 2016

Confusion persists over how government contractors should apply Medicare's regulations for determining inpatient status when a hospital stay spans less than two midnights.

A temporary suspension of initial reviews for Medicare reimbursement of short-term patient stays in hospitals could stretch through the end of July, a CMS spokesperson said Tuesday.

In the latest twist of the so-called two-midnight rule's course toward full implementation, the Centers for Medicare & Medicaid Services told government contractors early last month to suspend initial reviews of Medicare claims for inpatient stays shorter than a span of two midnights.

Under the rule, which has been in place since October 2013 and was significantly revised in October 2015, most hospital stays spanning a period of less than two midnights are considered inappropriate for designation as inpatient status and are ineligible for Medicare A reimbursement.

Last October, CMS announced that initial two-midnight rule reviews would be shifted from Recovery Audit Contractors to Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIOs).

Two companies were contracted to conduct the reviews: Annapolis Junction, MD-based Livanta and Harrisburg, PA-based KEPRO.

'Temporary Pause' in Reviews of Denied Two-Midnight Rule Claims

On June 6, CMS posted a message on saying that it ordered BFCC-QIO contractors to reexamine "all claims they denied in their medical review process since October 2015 to make sure medical review decisions and subsequent provider education are consistent with current policy. The current 'pause' will allow time for the BFCC-QIOs to conduct these re-reviews."

Ronald Hirsh, MD, FACP, has been advising hospitals on how to comply with the two-midnight rule since its inception. The vice president of the revenue-cycle solutions provider Accretive Health's regulations and education group, says he expects "a very short suspension" of the QIO reviews.

Hirsch offers seven points for hospitals to know about the two-midnight rule:

  1. The basics of the rule have not changed since it was introduced. Patients with an expectation of two medically necessary midnights in the hospital or who spend two medically necessary midnights in the hospital should be admitted as inpatients.
     
  2. Determining medical necessity for hospital care involves physician judgment. Physicians should be documenting the factors that make treating patients in a doctor's office or at a nursing facility unsafe.
     
  3. Medicare pays hospitals to provide services seven days a week. If hospitals keep patients an extra day because they do not offer a test or service on a weekend or holiday, that is not a medically necessary day.
     
  4. Do not use the outcome of a case to retrospectively review a short stay. Hospitals should only use the information available at the time of the admission decision to determine whether the right status was chosen.
     
  5. Every inpatient admission that spans less than two midnights—unless it was an inpatient-only surgery, death, or transfer—should be reviewed prior to billing to ensure the correct status was chosen.
     
  6. Hospitals that aggressively admitted high-risk patients with an expected short stay prior to the two-midnight rule can now expect a markedly higher observation rate under the rule.
     
  7. Do not leave patients on observation status for periods of time longer than two midnights. If patients have medical necessity for hospital care, admit them as inpatients. If they do not, send them home.

Christopher Cheney is the CMO editor at HealthLeaders.

Tagged Under:


Get the latest on healthcare leadership in your inbox.