Industry News

CMS Announces Changes to Two Midnight Rule Probe and Educate Reviews.

The Centers for Medicare & Medicaid Services (CMS) announced that Quality Improvement Organizations (QIOs) will assume responsibility from the Medicare Administrative Contractors (MACs) for conducting short stay patient status reviews, effective October 1, 2015.  Short stay patient reviews, or “probe and educate reviews,” are conducted as part of the Two-Midnight Review.  From October 1, 2015 to December 31, 2015, QIOs will conduct short stay patient status reviews based on current Medicare payment policies.  MACs will continue to conduct CMS-approved claim reviews unrelated to patient status, such as coding reviews and reviews to determine the medical necessity of a procedure.

Further, CMS will not approve Recovery Auditors to conduct patient status reviews for dates of admission of October 1, 2015 through December 31, 2015.  Beginning January 1, 2016, Recovery Auditors may only conduct patient status reviews for providers referred by the QIO for persistent noncompliance with Medicare payment policies.  Examples of persistent noncompliance include:

  • High denial rates;
  • Consistent failure to adhere to the Two Midnight Rule; and
  • Failure to improve performance after a QIO educational intervention.

The announcement is available at:

Centers for Medicare & Medicaid Services.  “Inpatient Hospital Reviews – Update 8/12/15.”  12 Aug. 2015.