Knowledge Base Article

With the major changes to Medicare’s inpatient admission requirements, trying to keep up with all the nuances of the rules and education efforts is like trying to juggle bowling balls. The Probe and Educate Review Process is replacing most previous Medicare Administrative Contractor (MAC) reviews, so this article addresses some questions concerning this process. If you have other questions, please refer to the resources listed at the end of this article or send me an email.

What is the purpose of the Probe and Educate Review Process?

The Probe and Educate Review Process is a focused prepayment medical review strategy for MACs designed to ensure provider understanding of the new two-midnight benchmark for determining the necessity of an inpatient admission (42 CFR 412.3) and to provide responsive provider-specific education, as necessary, to correct improper payments.

How long will the Probe and Educate Review Process last?

At the end of January, CMS decided to extend the Probe and Educate Review Process through September 30, 2014.

Will the MAC actually deny inpatient claims for not meeting the new inpatient criteria (2 midnight benchmark) during the Probe and Educate program?

Yes, claims that do not meet the two-midnight benchmark for an appropriate inpatient admission will be denied. Because the probe reviews will be conducted on a prepayment basis, hospitals can rebill for medically reasonable and necessary Part B inpatient services provided during denied Part A inpatient hospital stays provided the denial is on the basis that the inpatient admission was not reasonable and necessary. Hospitals may rebill for Part B inpatient services in accordance with Medicare Part B payment rules and regulations.

Will other Medicare review contractors be allowed to audit records for the medical necessity of inpatient admission?

No, Recovery Auditors and other Medicare review contractors will not conduct post-payment patient status reviews of inpatient hospital claims with dates of admission on or after October 1, 2013 through October 1, 2014.  

What types of inpatient claims will be selected for review by the MACs under the Probe and Educate Review Process?

MACs will select Medicare Part A inpatient claims spanning 0 to 1 midnight after formal inpatient admission.

Will claims containing inpatient-only procedures with stays less than 2 midnights be included in the Probe and Educate reviews?

No. However, CMS indicated on the last Special Open Door Forum concerning the new 2-midnight rule, that the contractors are not able to easily identify inpatient only procedure admissions up front. These claims may be initially selected for review, but will be released for payment when the MAC determines it was an inpatient–only procedure.

How many claims can a hospital expect to be selected for review?

MACs will initially select 10-25 records per hospital (25 for large hospitals, although “large” has not been defined). If a hospital has more than 1 error in a 10 record sample or more than 2 errors in a 25 record sample, after a three month education period, a repeat Probe & Educate sample of 10-25 records will be selected. Continuing problems of major concerns (7/10 or 14/25 errors) after a second three month education period could result in a third sample of 100-250 records for that hospital.

How will I be notified of the request for records for the Probe and Educate Review Process?

Providers will receive additional development requests (ADR) through the normal process. Providers that have claims selected for prepayment review may receive an ADR letter through the mail or will receive an ADR notice via the Fiscal Intermediary Standard System (FISS). Providers should monitor the Fiscal Intermediary Standard System (FISS) for claim status instead of seeking hard copy request for ADRs.

The MACs have published announcements on the Probe and Educate program; some include specific information on the ADR edits; for example Cahaba GBA 2-midnight ADR information, Novitas Probe and Educate information, and Palmetto Probe Reviews.

What elements will the MAC be looking for in the inpatient record for the Probe and Educate Review Process?

MACs will assess the hospital’s compliance with three things:

1. the admission order requirements,
2. the certification requirements, and
3. the 2-midnight benchmark

Will I be notified of the results of the reviews and if so, how?

Yes. MACs will send detailed results letters to providers for both denials and reviews with no findings.

Can the MAC and other Medicare Review Contractors audit inpatient claims for issues other than the medical necessity of the inpatient admission?

Yes. Medicare review contractors may review claims to ensure the services provided during the inpatient stay were reasonable and necessary in the treatment of the beneficiary, to ensure accurate coding and documentation, and may conduct other reviews as dictated by CMS and/or another authoritative governmental agency.

CMS will also monitor provider billing trends for variances indicative of abuse, gaming, or systematic delays in the submission of claims, for the purpose of avoiding the MAC prepayment probe audits during this initial probe and educate period.  Any evidence of systematic gaming, abuse or delays in the provision of care in an attempt to receive the 2-midnight presumption could warrant medical review.

Where can I obtain additional information about the Probe and Educate Review Process?

• Inpatient Hospital Reviews webpage
• See the following downloads at the bottom of this page:
• Questions and Answers Relating to Patient Status Reviews
• Selecting Hospital Claims for Patient Status Reviews
• Reviewing Hospital Claims for Patient Status
• MLN Matters Article SE1403
• Also check your local MAC’s website