CMS has ordered the Medicare Administrative Contractors (MACs) to re-review all denied claims for admissions under the “two-midnight” rule. The Final Rule CMS-1599-F has proven to be difficult to implement. On 2/24/14, CMS issued new guidance, whereby CMS is waiving the timeframe for filing redetermination requests for appeals received before 9/30/14 for claims denied before 1/30/14 under the Probe and Educate process. The MACs are re-reviewing all claim denials under the Probe & Educate process to ensure claim decisions and education is consistent with recent clarifications from CMS. With CMS calling for the MACs to re-review denied “two midnight” admissions, documentation of medical necessity remains important.
Here’s a link to the CMS guidance: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html
Generally the “two-midnight” rule requires patients to remain in a hospital bed to qualify for inpatient care. As a result of claims being denied that may not be supported by recent updates, CMS is allowing for handling outside of the normal appeal process for denied claims.
By Denise Bloch