CMS Final Rule 'Permanently' Removes Two-Midnight Payment Cut
Dive Brief: CMS on Tuesday finalized the 2017 Medicare payment rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System. The agency, under the final legislation for 2017, is “permanently removing” the -0.2% adjustment of compensation for inpatient services related to the “two-midnight rule.” This will increase FY 2017 payments by approximately…
CMS Final Rule ‘Permanently’ Removes Two-Midnight Payment Cut was originally published on
UnitedHealth will drop most of its Obamacare business, and Wal-Mart just waded into the prescription drug pricing debate. But first: A victory for providers in CMS’s latest inpatient payment proposal. CMS BACKS DOWN ON TWO-MIDNIGHT RULE — The much-derided, much-delayed provision was set to have major implications for hospital reimbursement; instead, CMS on Monday said…
CMS Backs Down on Two-Midnight Rule was originally published on
CMS Proposes Changes to Two-Midnight Rule for 2016
This July, the Centers for Medicare and Medicaid Services (CMS) issued the 2016 Proposed Rule for the Medicare Program. Though the proposed rule includes expected annual modifications to Medicare payments, a major highlight is the changes proposed to the two-midnight rule, which will significantly impact hospital medical coding in 2016.
Read More: CMS Proposes Significant Changes to Two-Midnight Rule for 2016
Patient Management Aided By Case Management Expertise
A highly regulated healthcare system is bound to create complex systems for patient status management. Healthcare institutions and medical workers are already required to provide round-the-clock observations and thorough documentation of patient status from the moment a patient enters the hospital or clinic through the time of discharge. This is a complex and labor-intensive process which requires the skill and knowledge of well-trained medical case managers.
The Role of Case Management
Case management ensures that patients are given the best care possible. It relies on planning, observation, and evaluation, with each important task delegated to specific members of the healthcare team. Case management ensures collaboration and communication among different healthcare providers to give the patient continuous quality medical care. This includes the management of patient status, especially for those who are critically ill or disabled and require intensive, round-the-clock care. Specific roles played by case managers include:
· patient classification for admissions
· identification of inpatient procedures
· early discharge planning
· utilization reviews for all patients
· payer reviews at all stages of the revenue process
· ensure that all admission days are authorized by discharge date
· execution of discharge plan
· evaluation
· appeals for RAC denials
· patient follow-up
Extensive Case Management and Its Part in the Revenue Cycle
Case managers are liaisons who bridge the gap between the patient and the healthcare team. They hold a unique position that supports the revenue cycle because they also bridge the gap between the clinical and financial departments. The expertise that case managers have regarding healthcare consulting will prove indispensable, especially with the expansion of the criteria for care which has been modified to include readmissions. The transition to ICD-10 also means that patient status management personnel will become even more in demand as hospitals and medical health personnel try to familiarize themselves with a new set of codes and additional procedures. Management expertise can help medical institutions reduce errors in documentation and procedures that could place them at risk for denials, and ensure timely and full compensation for patient care.
Case management becomes an even more integral part of health care with the Two-Midnight Rule, which is expected to increase the use of observation status in affected hospitals (although the Two-Midnight Rule was created to produce the opposite effect). A study done by the University School of Milwaukee revealed that non-clinical factors—such as time of day that the patient went into the hospital as well as the specific day on which the patient appeared—can affect the physician's determination to place the patient for observation under the Two-Midnight Rule. Expert case managers can work with physicians to make accurate assessments regarding the propriety of patient admissions.
It is true that the recent overhauls in medical processes due to health care reforms mean that hospitals and personnel need to adapt to a new and more complex system of patient management. However, there is always a good chance for success with a mobilized case management team who can serve as an effective partner for full compliance.
Make sure your staff is prepared for the ICD-10 rollout. Contact Provident Consulting for expert help today.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com
The policy also helps providers accurately determine inpatient status and increase hospital payments. Under the rule, if a patient stays for less than two midnights, the hospital is only eligible for the lower Part B reimbursement. Patient stays listed under Part B do not make a patient eligible for Medicare-covered nursing and rehabilitative services, which require patient stays of three nights or more.
Billing under Plan A according to the Two-Midnight Rule requires hospitals to present complete documentation that justifies the patient's stay, including the following information on the patient's medical record:
the fact of admission
reason for admission
that the physician expects the patient to be admitted for at least two midnights
reason for the length of stay
The Consequences of Non-Compliance
Non-compliance with this Medicare policy is accompanied by non-punitive measures and, most often, the denial of reimbursement claims. Hospitals risk RAC denials when documentation is incomplete or when the recovery auditing agency deems the justification for hospital stays insufficient to warrant a Class A payment.
It is important for hospitals to comply with this rule to ensure reimbursement. This means not only that proper documentation must be implemented, but also that physician cooperation is present. Physicians are tasked with making the decision to admit the patient and must give the basis to determine whether or not an inpatient status is medically necessary. Hospitals must also re-evaluate and redouble care coordination efforts, improve care management programs, and improve data and analytic systems.
Claims will be reviewed before being approved for payment. If there are issues regarding compliance, the administration contractors will work with the hospital to correct any errors. Medicare is allowing hospitals to acclimate to this new policy before healthcare reviews are conducted. While Medicare is taking appropriate steps to make the transition to this new policy as painless as possible, hospitals must remain vigilant and enact measures to ensure full compliance. It is also important to educate patients about observation status and its financial implications in order to establish expectations about care and ultimately improve patient satisfaction scores, which also plays a role in the grant of medical reimbursement.
Make sure you are complying with the Two-Midnight Rule. Contact Provident Consulting for expert advice.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com/
