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House Members Ask HHS for Clarification on 96-Hour Payment Rule

Analysis  |  By Jay Asser  
   July 27, 2022

Critical access hospitals (CAHs) have not had to abide by the rule in recent years due to financial strains and COVID, but there is concern of future enforcement.

In a letter to HHS, a bipartisan group of 25 House members has asked for clarification on the enforcement of Medicare's 96-hour payment rule for CAHs after the COVID-19 public health emergency (PHE).

The members, in their written remarks to HHS secretary Xavier Becerra, conveyed the potential ramifications of the rule if it is not continued to be waived as it has during the PHE to help CAHs survive the impact of the pandemic.

Established through the Balanced Budged Act of 1997, the rule requires CAHs to certify inpatients will be discharged or transferred to another hospital within 96 hours of admission to receive payment. CAHs are also required to ensure inpatient stays are below 96 hours on an annual average basis.

After COVID surged, the rule became nearly untenable as many patients required long hospital stays. However, even before the pandemic, the members argue that the rule put CAHs in difficult positions which resulted in patients not receiving care or being forced into unnecessary transfers to other facilities, while the hospitals often had to forego payment.

"Even after the PHE formally ends, COVID and other respiratory diseases are likely to cause some patients to need hospitalizations lasting longer than 96 hours," the representatives wrote. "These and other patients who can safely and effectively be treated in their local hospital deserve the option of receiving care closer to their homes, families, and usual doctors."

Though the 96-hour rule has not been enforced in the last several years, the members express concern that the end of the PHE will mark a return.

Specifically, they seek answers to the following five questions by September 9:

  1. Upon termination of the COVID-19 PHE, do you intend to reinstate enforcement of the 96-hour conditions of participation or payment?
     
  2. What rationale was employed in determining whether the condition(s) would be enforced following the PHE?
     
  3. If either condition will be enforced after the end of the PHE, will there be a grace or phase-in period before penalties will be applied to CAHs that fail to meet the condition(s)?
     
  4. What impact do you believe enforcement would have on the outcomes of patients hospitalized for treatment of COVID-19, pneumonia, and other acute respiratory infections?
     
  5. Do you support legislative efforts to repeal either or both of the 96-hour conditions?
     

With the PHE set to end on October 13, governing bodies of healthcare need to consider what a post-COVID landscape looks like and how the enforcement of a rule like the 96-hour stipulation would impact providers and patients.

Jay Asser is the contributing editor for strategy at HealthLeaders. 


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