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Two-Midnight Rule Must be Fixed or Replaced, Say Providers

Christopher Cheney, for HealthLeaders Media, March 3, 2014

"The probe and educate review will be beneficial to find out whether hospitals are complying," Bathija said. "It requires the MACs to be consistent. All of the MACs across the country will use the guidance from Jan. 30 to evaluate claims."

Under the rule, which CMS issued last year on Aug. 2, hospitals that admit patients for less than two nights will receive reimbursement at Medicare B outpatient rates. The rule states that hospital admissions shorter than two midnights in length are "generally inappropriate for payment under Medicare Part A, regardless of the hours the patient came to the hospital or whether the patient used a bed."

CMS made its case for the so-called "Two-Midnight" policy in a prepared statement released with the final rule on Aug. 2. "The rule improves value and quality in hospital care and provides clarification about when a patient should be admitted to the hospital and responds to recent concerns about extended Medicare beneficiary stays in the hospital outpatient department," CMS officials said.

"The rule also moves forward with health care delivery system reforms made possible by the Affordable Care Act. These include a new program aimed at improving safety in hospitals and refining the Hospital Readmissions Reduction program."

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3 comments on "Two-Midnight Rule Must be Fixed or Replaced, Say Providers"


Lisa Sams MSN, RNC (3/11/2014 at 12:31 PM)
As an APN of many years I would like to bring the focus back to The Patient. On the surface the Two Midnight Rule looks very much like a way to establish two standards of care. It is a woeful development for patient care and the clinical patient relationship. The unintended consequences of most regulations is the very human behavior that will find work arounds to rules that make little sense for the problems at hand. This rule is all about the money. Do we want to improve the systems of care, the outcomes for the people who trust us to care for them? Or will misguided regulations continue to erode the heart of health care...the patient clinicians relationship? The window of time to re-focus and get things on the right path is very limited.

Cheryl (3/7/2014 at 7:49 AM)
Some hospitals appear to have used observation stays to circumvent the re-hospitalization penalties or other payment/penalty issues. This rule helps those people who had a 3 day hospital stay but were denied their Medicare Part A benefits as the stay was considered "observation". In many cases the patient had no idea that they weren't inpatient. The decision define stay as observation or inpatient is also often made retroactively. I have called to determine status of a stay only to be told a week later that the stay is something different. In this instance the benefit to the patient is after the acute stay when they then require subacute skilled services.

Stefani Daniels (3/3/2014 at 9:27 AM)
In my opinion, this whole '2 MN' rule is a product of poor patient management. If hospitals had clamped down on physicians who let their patients linger in observation for more than 23 hours; if hospitals hadn't cohorted observation patients with inpatients and allowed community based physicians to manage them on a day to day basis rather than the hour to hour basis that they require; if hospitals had kept observation patients 'vertical' in an area cleared marked as 'outpatient observation;' if hospitals had invested in nursing staff who were schooled in the management and information needs of observation patients and their families; and if hospitals spent time educating their community about the kinds of services an acute care facility provide, then all of this 'mess' could have been avoided. Like the 24 hr guidance previously on the books, the 2MN rule doesn't change the fact that complete and accurate documentation must support the physicians decision to admit a patient to acute level of care, despite the anticipated or actual length of stay.