News & Analysis as of

Two-Midnight Rule Medicare

Stevens & Lee

CMS Final Rule: Medicare Advantage Plans Subject to Two-Midnight Coverage Condition

Stevens & Lee on

On June 5, 2023, CMS’s Final Rule regarding, among other things, “Technical Changes to the Medicare Advantage Program” will become effective – refer to the CMS Fact Sheet and the Final Rule as published in the Federal...more

Health Care Compliance Association (HCCA)

MA Final Rule: CMS Requires Two-Midnight Rule, Puts Limits on Internal Coverage Criteria

In what passes for neon lights in the regulatory world, CMS said Medicare Advantage (MA) plans must follow the two-midnight rule, its case-by-case exception and the inpatient-only (IPO) list, according to the final 2024 rule...more

King & Spalding

OIG Announces Resumption of Medicare Inpatient Short Stay Audits

King & Spalding on

In its November 2020 Work Plan update, OIG announced it will begin auditing short stay inpatient hospital claims under the Two Midnight Rule, and when appropriate, recommend overpayment collections. OIG does not specify the...more

Hogan Lovells

FCA Alert: Decision Opens Door to Challenge of Agency Guidance in False Claims Cases

Hogan Lovells on

On November 5, 2019, the United States District Court for the Eastern District of Pennsylvania ruled on a motion to dismiss a False Claims Act (FCA) qui tam suit filed by the United States Department of Justice, long after it...more

King & Spalding

How Payers Are Improperly Underpaying Inpatient Services As Observation Services

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Health plans and their delegated IPAs are using a number of different tactics to deny payment for inpatient services by improperly classifying inpatient claims as observation or other types of outpatient status. Payers are...more

Morgan Lewis

CMS Forges Ahead with Price Transparency, Major Payment Reductions in Proposed OPPS Rule

Morgan Lewis on

The Centers for Medicare and Medicaid Services’ proposed outpatient prospective payment system rule contains a number of significant changes and proposals impacting hospital operations and payments in calendar year 2020,...more

King & Spalding

CMS Temporarily Pauses QIO Short Stay and Higher Weighted Diagnosis-Related Group Review

King & Spalding on

Effective May 8, 2019, CMS temporarily suspended Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) Short Stay reviews and Higher Weighted Diagnosis-Related Group (HWDRG) reviews. Reviews will be...more

King & Spalding

HHS Argues It Cannot Be Sued by Patients for Hospitals’ Admission Decisions

King & Spalding on

n a motion filed last week in Alexander v. Azar, No. 3:11-cv-1703-MPS (D. Conn.), HHS argued that it cannot be sued by Medicare beneficiaries objecting to a hospital’s decision to admit them as inpatients instead of placing...more

King & Spalding

CMS Releases, Then Withdraws, Additional Guidance Regarding Application of Two-Midnight Rule to Total Knee Arthroplasties

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On January 8, 2019, almost exactly a year after CMS removed total knee arthroplasties from the Medicare Inpatient-Only List, CMS released additional guidance regarding the application of the Two-Midnight Rule to these cases. ...more

King & Spalding

Texas Health System Pays Nearly $2 Million To Settle Allegations of Improper Billing for Inpatient Services

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On May 14, 2018, the U.S. Attorney’s Office for the Southern District of Texas announced that Memorial Hermann Health System (MHHS) will pay $1,929,071.38 to resolve allegations that it improperly billed government healthcare...more

King & Spalding

CMS Proposes Changes to Inpatient Admission Orders in 2019 IPPS Proposed Rule

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On April 24, 2018, the Centers for Medicare & Medicaid Services (CMS) released the Fiscal Year (FY) 2019 Inpatient Prospective Payment System (IPPS) Proposed Rule (CMS-1694-P). Among other changes, CMS proposes eliminating...more

King & Spalding

Iowa Hospital Settles False Claims Act Case for Inpatient Claims Submitted Under the Two Midnight Rule

King & Spalding on

Genesis Medical Center in Davenport, Iowa has reached a settlement with the Department of Justice related to improper hospital admissions from January 1, 2013 to December 31, 2016. According to the DOJ, Genesis “improperly...more

King & Spalding

CMS Announces Expansion of Targeted Probe and Educate Medical Review Strategy

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On August 14, 2017, CMS announced an expansion of a Targeted Probe and Educate (TPE) review strategy for Medicare Administrative Contractors (MAC) reviews. Many providers were familiar with Probe and Educate reviews in...more

King & Spalding

CMS Updates the Medicare Program Integrity Manual to Reflect Patient Status Reviews Under the Two Midnight Rule

King & Spalding on

Although the Two Midnight Rule became effective on October 1, 2013, CMS had not updated manual guidance to incorporate the Two Midnight Rule until recently. The CMS updated the Medicare Benefit Policy Manual earlier this...more

Baker Donelson

Medicare Two-Midnight Rule and Observation Status Updates

Baker Donelson on

What's new from Medicare in the areas of the Two-Midnight rule and observation services? CMS recently published updates to a Medicare manual reflecting clarifications to its Two-Midnight policy, a Medicare Quality Improvement...more

King & Spalding

CMS Updates Manual Guidance to Include References to the Two Midnight Rule

King & Spalding on

Although the Two Midnight Rule was effective October 1, 2013, until recently, CMS had not updated the Medicare Benefit Policy Manual (MBPM) to incorporate the Two Midnight Rule and its revisions to prior admission...more

King & Spalding

HHS OIG Issues Report on Medicare’s 2-Midnight Rule

King & Spalding on

On December 19, 2016, the HHS OIG issued a report on Medicare’s 2-midnight rule titled “Vulnerabilities Remain Under Medicare 2-Midnight Hospital Policy.” The report reviews data from 2013 and 2014 and reaches several...more

McDermott Will & Emery

OIG Issues Report on Medicare’s ‘2-Midnight Hospital Rule’

McDermott Will & Emery on

On December 19, 2016, the US Department of Health and Human Services Office of Inspector General (OIG) posted a report examining the Centers for Medicare & Medicaid Services’ (CMS’s) “2-Midnight Rule.” The OIG concluded that...more

Foley & Lardner LLP

Hospital Short-Stay Review Ban Lifted by CMS

Foley & Lardner LLP on

Effective September 12, 2016, the Centers for Medicare & Medicaid Services (CMS) lifted the temporary ban on patient status reviews of hospital short stays for Medicare beneficiaries. Those reviews are currently conducted by...more

Sheppard Mullin Richter & Hampton LLP

CMS Releases 2017 Medicare Hospital Payment Rates, Penalties for Poor Performers

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (Final Rule) modifying the Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) Prospective...more

King & Spalding

CMS Releases FY 2017 Hospital Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Final...

King & Spalding on

On August 2, 2016, CMS released a final rule (Final Rule) with updates to the Hospital Inpatient Prospective Payment System (Hospital IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) affecting...more

Hinshaw & Culbertson LLP

Significant Hospital Related Mid-Year Updated OIG Review Activities

This is the second of three alerts discussing the mid-year update to the Fiscal Year 2016 Work Plan issued by the Office of Inspector General (OIG). In the first alert we discussed the top management performance challenges...more

BakerHostetler

FY 2017 IPPS Proposed Rule Results in Modest Increase for Hospitals

BakerHostetler on

CMS recently issued a proposed rule updating fiscal year (FY) 2017 Medicare payment policies and rates under the Medicare inpatient prospective payment system (IPPS) and the long-term care hospital (LTCH) prospective payment...more

King & Spalding

CMS Issues Final Rule for CY 2016 OPPS and Changes to the Two-Midnight Rule

King & Spalding on

On October 30, 2015, CMS issued its final rule with comment period (Final Rule) for the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for...more

Mintz - ML Strategies

Health Care Update - November 2015

Mintz - ML Strategies on

Ways & Means Leadership Changes – Health Policy Implications Looming: As Congress pushes forward with a two-year budget deal, and new Speaker Paul Ryan begins his tenure as the top Republican in the House of...more

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