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Kesha Boykin-McLean

By: Kesha Boykin-McLean on July 22nd, 2014

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The Two Midnight Rule: Are you ready?

Credentialing | Compliance

The “Probe and Educate” period for the “Two Midnight Rule” (42 CFR § 412.3) has yet again been extended, but the deadline of September 30th, 2014 is rapidly closing in.

How prepared are you? In anticipation of some common questions, we’ve put together this post to give you some necessary points of reference in ensuring you continue to receive proper reimbursement for your facility’s Medicare Part A claims.

The 4 most common reasons for claim denials

  • An insufficient or missing inpatient admission order. For an admission order to be considered complete, it must be written by a medical practitioner knowledgeable about the patient’s current condition. It must be placed at or before the time of admission and both present in the record and supported by physician admission and progress notes.

  • Short-Stay procedures. A short-stay procedure is any procedure with a length of stay with a duration of less than two midnights. These types of stays are considered an “inappropriate” application of Medicare Part A.

  • Short stays for medical conditions when the record doesn’t support an exception. For example, if the notes simply state that the physician would observe patient overnight to monitor. This is also an application of the “Two Midnight Rule” in combination with the next scenario.

  • Physician attestation statements without supporting documentation. The documentation must allow for a stay of the specified duration for the claim to be considered sufficient.

What steps can I take to prepare?

  • Revise your admission and certification forms. It’s just a best practice to make sure that your forms change as requirements do. It is recommended that you combine your Order and Certification forms into one form. This will give you the ability to justify a claim from within the same document that orders it.

  • Educate Physicians on Requirements. Discuss appropriate documentation and the importance of clear wording.

  • Medical Staff and Credentialing. Admitting physician must have the proper privileges. If they don’t, they will be unable to file the paperwork on their own behalf, which in itself will put you out of compliance, causing the claim to be denied. Review hospital/medical staff policies on admitting privileges and verbal orders. Revise them to comply with the rules if necessary.

  • Revise hospital policies and educate staff. As stated above, an informed staff is necessary to ensure reliable compliance.

  • Conduct self-audits and implement corrective action where needed. Remember, compliance is important to your patients, your integrity, and your bottom line. The cost of failure to adjust to these changes can be disastrous.

As of this post, there is still plenty of time to get yourself ready to face the challenges of 42 CFR § 412.3. And hopefully, now that you have this action plan, there’s no way it will break your stride.


About Kesha Boykin-McLean

As Chief Compliance Officer, Kesha Boykin-Mclean brings over 20 years of experience in healthcare. Prior to joining VCS, Boykin-Mclean held a number of senior-level compliance roles, including managing and developing the compliance program for St. Francis Hospital in Connecticut. She was also the Division Ethics and Compliance Officer for the Hospital Corporation of America’s Gulf Coast Division where she was responsible for oversight of compliance programs for all hospitals within the division. Most recently, she served as an independent healthcare consultant, assisting hospitals with the planning and implementation of compliance programs.