Mar. 3—Medicare auditors were ordered to re-review any “probe and educate” audits that led them to reject hospitals’ claims during the phased-in enforcement of Medicare’s two-midnight rule.

The Centers for Medicare & Medicaid Services (CMS) recently announced it will require Medicare administrative contractors (MACs) to re-review all claims denied since Oct. 1, 2013, under the probe-and-educate process, which allowed review of a limited number of claims and was instituted to begin enforcement of the two-midnight admissions rule. Full enforcement of the two-midnight rule, which requires physician certification that a patient’s condition required hospitalization for at least two midnights to qualify for Medicare Part A payment, was delayed until Oct. 1, 2014.

The re-reviews were intended to ensure that the decisions and subsequent education were consistent with the agency’s clarifications  regarding the two-midnight rule on Jan. 30.

If the re-review determines that the previously rejected claim is payable, then the MAC may reverse its decision and issue payment outside of the appeals process. 

The agency urged hospitals to check whether rejected claims have undergone re-review before appealing the rejection. CMS also sought to limit the impact of the re-review process on hospitals’ appeal rights by waiving the 120-day limit on redetermination requests for any probe-and-educate denials that occurred before Jan. 30, 2014, and filed before Sept. 30, 2014.

Claim denials affirmed under re-review will automatically be transferred into the appeals process, according to CMS.

The agency also released initial data on the inpatient hospital probe and educate reviews and examples of common denials that occurred. 

Publication Date: Monday, March 03, 2014