Breaking News: Medicare Advantage Must Follow Two-Midnight Rule

Dr. Ronald HirschJuly 24, 2023


With an extremely compressed timeframe, the Centers for Medicare & Medicaid Services (CMS) released CMS-4201-F, the rule setting new regulations for Medicare Advantage (MA) plans. As I reported in a previous RACmonitor News article, in December 2020, CMS proposed to codify the requirement that MA plans follow the Two-Midnight Rule, including the Inpatient-Only List. Then, only a few weeks after the comment period closed, during which 887 comments were submitted, CMS sent the final rule to the Office of Management and Budget (OMB) for approval on March 8; approval was issued on March 31, and the final rule was released April 5.

 

And as expected, the final rule codifies the requirement that MA plans do indeed have to follow the Two-Midnight Rule and the Inpatient-Only List. CMS specifically notes that MA plans must not only follow the two-midnight benchmark – when a physician admits a patient as an inpatient with the clinically appropriate expectation that the patient will need two midnights of necessary hospital care – but also the “case-by-case exception,” wherein two midnights are not expected, but based on complex medical factors documented in the medical record, inpatient care is nonetheless necessary.

 

Read the full article here. 



Author Bio: Dr. Ronald Hirsch is Vice President of the Regulations and Education Group at R1 RCM Inc. Dr. Hirsch was a general internist and HIV specialist and practiced at Signature Medical Associates, a multispecialty practice located in Elgin, IL. He was Medical Director of Case Management at Sherman Hospital in Elgin, IL from 2006 to 2012, where he was Chairman of the Medical Records Committee from 1995 to 2012, and also served on the Medical Executive Committee. Dr. Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians, certified in Revenue Integrity by the National Association of Healthcare Revenue Integrity, and on the Advisory Board of the American College of Physician Advisors. He is on the editorial board of RACmonitor.com. He is the co-author of The Hospital Guide to Contemporary Utilization Review, with the third edition published in 2021.



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