The Two-Midnight Rule: A Review
Tóm tắt
Many years ago, The Center
for Medicare and Medicaid Services (CMS) created a system where patients who did not meet specific criteria were determined to be ‘outpatients’ and placed under observation status in the hospital. This status was intended as enhanced outpatient treatment to rule out a diagnosis. The original definition of observation status has, however, transformed to a system where ‘outpatients’ are regularly placed in a hospital bed, taken care of by inpatient physicians and receive the same hospitalized care as ‘inpatients’. The financial impact to patients placed under observation status is burdensome compared to an inpatient admission. Furthermore, patients placed in observation status do not qualify for Skilled Nursing Facility Medicare coverage (Centers for Medicare and Medicaid Services
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf
). In an attempt to clarify the difference between observation status and inpatient status and to decrease the number of prolonged observation stays, CMS has enacted a new set of regulations, The Final Rule, CMS 1599-F (Centers for Medicare & Medicaid Services
http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf
). This set of regulations has made the differentiation between observation status and inpatient admission anything but straightforward: the regulations are quite complicated and nuanced and have required major changes in hospital systems as well as physician thinking, increased risk of reimbursement denial and increased administrative costs.
Tài liệu tham khảo
Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 8: Coverage of Extended Care (SNF) Services Under Hospital Insurance, Sec. 20.1 CMS Publication 100-02. Rev. 183. April 4, 2014. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf. Accessed 3 June 2014.
•• Centers for Medicare & Medicaid Services. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care; Hospital Prospective Payment System and Fiscal Year 2014 Rates; Quality Reporting Requirements for Specific Providers; Hospital Conditions of Participation; Payment Policies Related to Patient Status; Final Rule. August 19, 2013. http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf. This reference is to the actual 2-Midnight rule from CMS and is the basis for the entire article and discussion.
MedPAC report to Congress: hospital inpatient and outpatient services. http://www.medpac.gov/documents/reports/mar14_ch03.pdf?sfvrsn=0.
Medicare Program; Hospital inpatient prospective payment systems for acute care hospitals. Fed. Reg. 78:50495–50907.
Sheehy A, Graf B, Gangireddy S, et al. Hospitalized but not admitted: characteristics of patients with “observation status” at an academic center. JAMA Intern Med. 2013;173(21):1991–8.
•• US Department of Health and Human Services. Office of Inspector General. Hospitals’ use of observation stays and short inpatient stays for Medicare beneficiaries. OEI-02-12-00040. 29 July 2013. The OIG released surprising data referenced in this article and additionally contributed questions and opinions regarding the current observation and inpatient status policy.
Sheehy A, Caponi C, Gangireddy S, et al. Observation and inpatient status: clinical impact of the 2-midnight rule. J Hosp Med. 2014;9(4):203–9.
Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual. Chapter 8: Coverage of Extended Care (SNF)Services Under Hospital Insurance, Sec 20.1. CMS Publication 100-02. Rev. 183. 2014. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf.
The Medicare Recovery Audit Contractor (RAC) Program: an evaluation of the 3-year demonstration. http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/recovery-audit-program/downloads/RACEvaluationReport.pdf.
http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html.
Centers for Medicare & Medicaid Services. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care; Hospital Prospective Payment System and Fiscal Year 2014 Rates; Quality Reporting Requirements for Specific Providers; Hospital Conditions of Participation; Payment Policies Related to Patient Status; Final Rule. 19 Aug 2013. http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf.
• Society of Hospital Medicine. The Observation Status Problem: Impact and Recommendations for Change. 2014. http://www.hospitalmedicine.org/CMDownload.aspx%3FContentKey%3Dbd419fbf-a86d-438e-826a-86e720e0543c%26ContentItemKey%3Dbdde0512-d58c-4706-9cf8-73dec7592704&rct=j&frm=1&q=&esrc=s&sa=U&ei=yE1WVKrnNoaUNqPGg6gP&ved=0CBQQFjAA&sig2=ug2eNWJTVUXHFRpQwx9o2w&usg=AFQjCNFAvt506TbpbWatdM6RxN1h5BjePg. SHM published this White Paper which is a thorough review of the current 2 midnight rule as well as opinion on the rule and suggestions for change.
American Hospital Association et al. v. Sebeliu, D.D.C., Case 1: 14-cv-00609 (filed Apr. 4, 2014). http://www.aha.org/content/14/140414-compliant-2midnight.pdf.