Probe and Educate’ MAC reviews in effect
MACs are performing pre-payment audits
When the Medicare Administrative Contractors (MACs) conduct "probe and educate" prepayment audits of compliance with the two-midnight rule, inadequate documentation and lack of one or more of the components of certification are major reasons for the denials, according to Ralph Wuebker, MD, MBA, chief medical officer for Executive Health Resources, a Newtown Square, PA, healthcare consulting firm.
"Hospital case managers and physician advisors have a big responsibility to ensure that all of the elements required under the rule are in place so the hospital can get paid," he says.
Responding to confusion in the industry about the two-midnight rule, the Centers for Medicare & Medicaid Services instituted the "probe and educate" prepayment reviews that assess hospital understanding and compliance with admission order and certification requirements and the two-midnight benchmark.
"The Medicare Administrative Contractors (MACs) can review 10 or 25 claims depending on the size of the hospital before payment is issued to determine if the hospital is complying with the provisions of the two-midnight rule. If hospitals are not complying, the MAC is required to educate them on what they should be doing," says Priya Bathija, JD, senior associate director for policy for the American Hospital Association.
According to Wuebker, "The [Protecting Access to Medicare Act of 2014] mandates another delay in the Recovery Auditors reviewing zero- and one-day stays until April 2015. But, it also gives discretion to the Secretary of Health and Human Services (which she already had) to extend the probe and educate for MACs as she sees fit. I would expect the RAs audits of one-midnights stays to be suspended until April 2015, but remember other auditors will continue reviews (MAC, OIG, DOJ, ZPIC)."
When the MACs issue a pre-payment denial for an inpatient stay, hospitals can appeal the denial or rebill for Medicare Part B services (if it’s within timely filing deadlines), he says.
CMS has instructed the MACs to take a second look at all claims that were denied under the "probe and review" process to make sure that the denials were valid under CMS’s recent clarifications on the two-midnight rule, physician orders, and certification requirements, says Andrew Wachler, Esq., manager partner of Wachler & Associates, PC, a healthcare law firm based in Royal Oak, MI. If the MAC determines that its decision to deny the claim was improper, the MACs may reverse the denial and issue payments without the hospital having to appeal.
"The re-reviews are what happens when providers are held responsible for new criteria before it has been fully vetted. Hospitals should welcome the re-reviews. First they may be reimbursed for the claims that were improperly denied. In addition, the review process will be less formalistic, and thus less costly and time-consuming than the normal appeals process," he says.
Reasons for denials
The MACs are denying claims for a variety of reasons, including the missing or unsigned orders for inpatient admissions, lack of medical necessity, and inpatient stays that do not span two midnights, Wuebker says.
Many denials have occurred in cases where it appeared reasonable to the physician that the stay would cross two midnights but the patient was discharged sooner, Wachler says. "Auditors appear to be giving more weight to the fact that the patient didn’t stay for two midnights than the reasons for the admission. The legislation pending before Congress directs CMS to address this issue and create admission criteria guidelines for short stays," he says.
"The MACs are definitely casting a wide net under probe and educate.’ Hospitals need to have an effective and consistent process to ensure that all of the components of the two-midnight rule are in the record and are clear," Wuebker says.
The two-midnight provision in the Inpatient Prospective Payment System final rule for fiscal 2014 requires that treating or attending physicians certify the inpatient admission by signing an inpatient admission order, stating the reason for the inpatient services, estimating the time physicians expect patients to be in the hospital, and including the plan for post-hospital care.
This means that both the time that the physician expects the patient to be in the hospital and documentation to support medical necessity for an inpatient admission must be clearly communicated, he adds.
"An inpatient admission must satisfy the time AND (not OR) the medical necessity component. It’s not sufficient to have one or the other. Both elements have to be in the record," he says.
For instance, it’s not enough for physicians to say they expect patients to be in the hospital for two midnights for a certain reason. The documentation must show medical necessity for the stay.
A common question right now concerns the use of screening criteria, Wuebker says. CMS has never required hospitals to use screening tools such as InterQual and Milliman, but the tools do help ensure consistency, Wuebker says.
"Hospitals don’t have to use screening tools, but they do need to have a process in place to ensure consistent and accurate decision-making. If hospitals rely on the attending physician to make the decisions, there is going to be incredible variability because physicians practice differently and very few are familiar with the Medicare requirements," he says.
