CMS announces delay in two-midnight rule enforcement
Pending bill may add another year to the hold
On January 30, the Centers for Medicare & Medicaid Services (CMS) announced a delay until Oct. 1, 2014, in post-payment Recovery Audit Contractor (RAC) audits of hospital admissions to determine compliance with the contentious "two midnight" rule.
Apparently, delaying enforcement was not enough to silence critics. Barely a month passed before two senators introduced a bill to delay the rule by another year and mandating that it be altered with input from the very stakeholders who dislike the regulation and have made their feelings so well heard.
Senators Robert Menendez (D-NJ) and Deb Fisher (R-Neb.) introduced the Two-Midnight Rule Coordination and Improvement Act on March 5. It would require a new regulation based on input from hospitals, physicians, and other interested parties. It would also give the force of law to the enforcement delay announced by CMS.
Meanwhile, the Probe and Educate prepayment audits conducted by Medicare Administrative Contractors (MACs) continue. At Middlesex Hospital in Middletown, CT, they have been having them fairly regularly, says Linda Jo Spencer, compliance officer for the facility.
"We have done well on them," she says, but that is despite the fact that if there are questions, it can take months for CMS to provide guidance. "It is hard to comply with something that still has so much about it that is not clear."
The hospital's director of quality, Claire Davis, RN, MHA, CPHQ, FNAHQ, adds that it is more than just the staff not being able to figure out the rules, but also the public. "We get complaints from patients and their families," Davis explains. When patients are released sooner than they might have thought or without being admitted, they get upset. Davis says it has impacted patient satisfaction scores in some cases.
Ultimately, the courts or Congress will step in to sort out what is a bad attempt to fix a real problem, says Mark Safalow, MD, the hospital's director of utilization review. "As doctors, we have to be sure we are aware of those one-day admissions and that they are appropriate," he says. "We needed to be made aware of those long observation patients, too. But this rule? Two midnights is just arbitrary."
Davis notes that two midnights can be as little as 24 hours and 1 minute, or nearly three days. Her colleague, John Machado, DO, the head of the hospitalist program at Middlesex, wonders what to do when a patient is admitted at 9 p.m. but the hospitalist does not see that person until 2 a.m. The orders then come in two hours after midnight. So is the clock set for when the admission starts or when the physician orders are in?
"This is the kind of question we keep having," Davis says. "We should be about doing what's right for the patient every time and documenting it." Trying to fit every patient into this rule that has only two boxes just is not working, she continues. It is hardly surprising that there have been delays and continued calls for change.
The proposed legislation that might bring change — S.2082 IS — is currently in committee and had not been scheduled for any debate as of press time. The text can be seen at http://beta.congress.gov/113/bills/s2082/BILLS-113s2082is.pdf.
Information about the RAC audit delay can be found on the CMS website at http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html.
Information about the ongoing Probe and Educate prepayment MAC reviews is available at http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/UpdateOnProbeEducateProcessForPosting02242014.pdf.
For more information on this story, contact:
- Mark Safalow, MD, Director of Utilization Review, John Machado, DO, Associate Director, Hospital Medicine, Linda Jo Spencer, CHPS, CHC, or Claire M. Davis, RN, MHA, CPHQ, FNAHQ, Director of Quality, Middlesex Hospital, Middletown, CT. Email: email@example.com