On Tuesday, the Centers for Medicare and Medicaid Services (CMS) ordered its Medicare Administrative Contractors (MACs) to take a second look at all of the claims that the MAC denied under the Probe and Educate review process. These re-reviews are being done to ensure that the MACs’ claim denials, and the education provided to the hospitals up to this point, is consistent with CMS’s recent clarifications regarding the two-midnight rule and physician orders and certification requirements. During the re-reviews, if the MAC determines that its previous decision to deny the claim was improper, the MAC may reverse the denial and issue payment outside of the Medicare appeals process.
While the re-review process is in effect, hospitals should contact their MAC to determine whether a re-review has taken place. Until this confirmation is received, hospitals should not file a redetermination appeal request. CMS announced that it will waive the 120 day timeframe for filing a redetermination appeal for any redetermination requests received before September 30, 2014 for Probe and Educate denials that occurred on or before January 30, 2014. If a hospital has already filed an appeal for a claim denial on or before January 30, 2014, that claim will also be subject to a re-review by the MAC. Upon re-review, if the MAC upholds its original denial decision, that claim will be automatically transferred to a redetermination appeal.
Hospitals should welcome the news for these re-reviews. First, there is the possibility that healthcare providers will be reimbursed for claims that were improperly denied upon initial review. Secondly, the re-review process will be less formalistic, and thus less costly and time-consuming than the normal appeal process.
Wachler & Associates will continue to monitor any further developments regarding CMS’s new inpatient admission rule. In the meantime, hospitals should continue to ensure its admission and documentation protocols comply with the new inpatient admission criteria and certification and order requirements. If you have any questions pertaining to the 2-midnight rule or certification and order requirements, or if you think that your entity may have had some of its claims under the two-midnight rule improperly denied, please contact an experienced health care attorney at Wachler & Associates via phone 248-544-0888 or firstname.lastname@example.org.