On November 15, 2013, CMS issued Transmittal 1315, a One-Time Notification (CMS Transmittal), instructing Medicare Administrative Contractors (MACs), Recovery Auditors and the Supplemental Medical Review Contractor not to conduct post-payment “patient status reviews” for inpatient claims with dates of admission between October 1, 2013, and December 31, 2013.  It defines “patient status reviews” as those reviews analyzing compliance with CMS’s final rule published on August 19, 2013, that is commonly known as the “two-midnight rule.”  CMS instructs the contractors that they may continue other types of inpatient hospital reviews during this time and claims with evidence of systematic gaming, abuse or delays in the provision of care in an attempt to surpass the 2 midnight presumption. 

CMS has issued Transmittal 1315 as part of the “Probe and Educate” reviews announced by CMS on September 26, 2013, and explained in additional guidance published in early November 2013.  Under the Probe and Educate program, MACs will conduct probe samples (of between 10 to 25 claims) of hospital inpatient stays to determine the extent to which hospitals are in compliance with the new inpatient order requirement, physician certification requirement and the two midnight admission standard.  MACs will educate providers on the result of these probe samples.  The initial set of probe samples will be drawn from inpatient claims with dates of admission between October 1, 2013, and December 31, 2013.  CMS confirmed during an Open Door Forum on November 12, 2013, that the cessation of patient status reviews for inpatient claims with dates of admission between October 1, 2013, and December 31, 2013, will be permanent; MACs and RACs will not be able to conduct patient status reviews of these claims after the Probe and Educate program is complete. 

The CMS Transmittal available here does not reflect CMS’s most recent guidance extending the “grace period” for patient status reviews for claims with dates of admission through March 31, 2014.  This guidance is available here.

Reporter, Kate Stern, Atlanta, +1 404 572 4661, kstern@kslaw.com.