Knowledge Base Article

Q:

When we perform a self-audit after a patient has been discharged and the documentation does not support a 2-Midnight expectation do we have to notify the beneficiary of the change from a Part A claim to a Part B claim?

A:

This question was addressed on pages 50913 – 50914 of the 2014 IPPS Final Rule.

Commenters asked that CMS clarify whether or not they were “proposing a self-audit process that would have to conform to the utilization review rules under the CoPs, notably physician concurrence, beneficiary notification, and other aspects related to continuation of an inpatient stay.”

CMS’s response was that “we did not propose and are not finalizing a policy that would allow hospitals to bill Part B following an inpatient reasonable and necessary self audit determination that does not conform to the requirements for utilization review under the CoPs. We do not agree with the commenters that beneficiaries need not be notified of a hospital’s determination that the inpatient admission was not reasonable and necessary. Part B billing pursuant to such a determination may result in an increase in financial liability for some beneficiaries which hospitals may not be able to ‘‘waive’’ or forego attempting to collect (we refer readers to sections XI.B.5 and B.6. of the preamble of this final rule). We believe that the CoP rules for beneficiary notification and physician involvement in hospital utilization review decisions are important for maintaining beneficiary rights, consistent with 42 CFR 482.13.”

§482.30 Condition of participation: Utilization Review

This CoP instructs that if after review the Utilization Review Committee determines that a stay was not medically necessary, written notification must be provided to the hospital, patient and MD responsible for the patient’s care, within 2 days of the decision being made.