CMS has released updated guidance on "probe and educate" audits related to the two-midnight rule.
CMS is asking Medicare administrative contractors to re-review all claim denials to date under the agency's probe and educate process to ensure the claim decision and subsequent education is consistent with clarifications CMS released Jan. 30 concerning the physician order and physician certification requirements for hospital inpatient admissions. MACs may reverse their decisions and issue payments outside of the appeals process if the claim is deemed payable after re-review.
The two-midnight rule is a new regulation included in the 2014 Medicare inpatient prospective payment rule. The policy established that inpatient admissions spanning at least two midnights qualify for Medicare Part A payments. Inpatient stays lasting fewer than two midnights must be treated and billed as outpatient services.
Following fierce opposition from hospitals and other healthcare groups, CMS delayed the two-midnight rule through Sept. 30. MACs and recovery auditors will not conduct two-midnight post-payment reviews of claims with admissions dates between Oct. 1, 2013, and Oct. 1, 2014. However, MACs and RAC will carry out prepayment reviews of hospital admissions that occur between March 31, 2014, and Sept. 30, 2014. Depending on the hospital, auditors will review 10 to 25 claims per facility.
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