CMS Posts Updates on Probe Educate Audits for Two Midnight Rule

19379278_lThe Centers for Medicare & Medicaid Services (CMS) posted February 24 additional updates on the “probe and educate” audits it is conducting in connection with new payment policies for Medicare Part A inpatient claims.

Under the 2014 Inpatient Prospective Payment System final rule, issued in August 2013, where a physician admits a patient with the assumption the stay will span at least two midnights, the admission will presumptively qualify as appropriate for payment under Medicare Part A. Conversely, admissions spanning less than that time period presumptively should have been provided on an outpatient basis under Medicare Part B. The rule took effect October 1, 2013 but its full implementation has been delayed through September 30, 2014.

As explained in previously released guidance, under a “probe and educate” review process, Medicare Administrative Contractors (MACs) are selecting 10 to 25 inpatient claims per hospital that span less than two midnights for “prepayment review” to determine medical necessity of the patient status in accordance with the new policy.

Based on the initial reviews, MACs will conduct additional educational outreach and repeat the process where necessary. In addition, during the transitional period Recovery Audit Contractors generally “will not conduct post-payment patient status reviews of inpatient hospital claims with dates of admission on or after October 1, 2013 through October 1, 2014,” CMS said.

The latest information posted by CMS includes a “status update” that highlights “common denials made during the ‘probe & educate’ period.”

CMS also said the agency is asking MACs “to re-review all claim denials under the Probe & Educate process to ensure the claim decision and subsequent education is consistent with the most recent clarifications.”

“To ensure that the re-review process does not affect the ability of a provider to file a timely appeal of a denied claim, CMS will waive the 120 day timeframe for filing redetermination requests received before September 30, 2014 for claim denials under the Probe & Educate process that occurred on or before January 30, 2014,” CMS said.

CMS added that claims denied under the probe & educate process before January 30 for which appeals have been filed also will be subject to re-review.

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