Case Management

What is best practice for reviewing reasonable and necessary under the 2-midnight rule?

Case Management Insider, November 10, 2015

Compliance with the 2-midnight rule can be tricky for many organizations, which has left many case managers with nagging questions about how to get it right. We got the following question from one of our readers and asked two of our experts, Steven Greenspan, JD, LLM, vice president of regulatory affairs at Executive Health Resources in Newtown Square, Pennsylvania, and Kurt Hopfensperger, MD, JD, vice president of compliance and physician education for Executive Health Resources, to weigh in with some guidance on how this facility should proceed.

Q: What have you found to be best practice for reviewing reasonable and necessary for inpatient status with the CMS 2-midnight rule?

A:
Best practice for reviewing the medical necessity of Medicare inpatient admissions has not changed with the institution of the 2-midnight rule. CMS provides guidance that the decision to admit a patient is a complex medical judgment made by a physician in consideration of several factors, including the following:

  • The patient’s age
  • Disease processes
  • The severity of the signs and symptoms of the patient’s medical condition
  • The medical predictability an adverse event

The best practice for review of admissions includes the consistent and reproducible application of evidence-based medical criteria, such as commercial screening tools, to all cases. A trained and experienced physician advisor, also utilizing evidence-based medicine and published medical literature, should review cases which fail the initial screening criteria.

Got something you want to ask our experts? If you’ve got questions about the 2-midnight rule or any other case management topic, please e-mail them to Kelly Bilodeau at Kelly@phbphoto.com and we will have one of our experts answer it and will publish the response in an upcoming issue of Case Management Insider.

 

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