When a doctor admits a Medicare beneficiary for inpatient care, his choice could be influenced by a Centers for Medicare and Medicaid Services (CMS) standard that sounds like a term from a spy novel: the two-midnight rule.
The two-midnight rule is used when a doctor believes a Medicare beneficiary needs hospital care that would likely eclipse two midnights—requiring inpatient care instead of cheaper outpatient care, Regan Tankersley, an attorney with Hall Render, a law firm that advises health care systems, said. Healthcare Brew.
“It’s a more expensive setting, it’s a more expensive care, and therefore it costs more to the payer,” she said.
CMS first implemented the two-midnight rule in 2013 to provide hospitals with a guideline for what types of health care are eligible for Part A coverage, which means the insurer covers full medical costs for services such as hospital inpatient care or time in hospital. skilled nursing facility. Under Part B coverage, which includes outpatient services, the insurer pays a smaller percentage of these costs, typically 80%. according to Medicare.
By mischaracterizing Part A coverage, a provider can overcharge the insurer for treatment, Tankersley said. Before rulemakers clarified what coverage might qualify under Part A, CMS auditors found inconsistencies in medical claims the agency received from hospitals.
“[T]Through the Recovery Audit program, CMS identified a high rate of errors regarding hospital services provided in medically unnecessary settings (i.e., inpatient rather than outpatient settings).” news bulletin stated.
According to 2016 data from the Department of Health and Human Services Office of Inspector General (HHS-OIG). reportIn 2014, Medicare may have paid nearly $3 billion for short-term hospital stays incorrectly classified as Part A.
On the other hand, mischaracterization of coverage as Part B may prevent patients from accessing coverage for certain services, such as admission to a skilled nursing facility, according to the report.
“It took some of the guesswork out of hospitals about when they should see patients,” Tankersley said.
This rule eliminated the “fear” on the part of the provider that “we admit them because we think they are sick enough, and then Medicare or the auditor comes back and says, “No, we think they should have been outpatients.” patients” and then they reimburse that payment,” she added.
Enrollment in Medicare Advantage (MA), a program in which private insurers contract with Medicare to provide coverage, has grown to more than 30 million enrollees, up from 14.4 million enrollees when the rule of two went into effect, according to KFF. midnight. Last June, CMS and HHS added new rule to the Federal Register: MA plan providers must also comply with the two-midnight fee structure.
“Many Medicare Advantage plans or commercial plans are preauthorized. [for inpatient admission]said Tankersley. Before the rule, MA plans could “come back and say, ‘No, we’re not going to allow this to be recognized.’ And then you go back to outpatient treatment and services.”
This article was originally published To Healthcarebranch Morning beer.