Since the onset of the 2-midnight rule, hospitals have been spared the onslaught of medical necessity denials from Recovery Audit Contractors (RACs). The RACs have certainly branched into other areas of audit in hospitals, but tightened claim limits have significantly...

OIG Raises Concerns About Service and Payment Denials Under Medicare Advantage Plans According to CMS, almost 37% of all Medicare beneficiaries will enroll in Medicare Advantage plans in 2019. In addition, the market remains very attractive to insurers who plan to...

Over the last few years, there has been a trend toward automating the medical necessity UR screening process using software to extract clinical data and either apply commercial criteria or create an acuity score. As I have strolled across trade show floors, I see...

In 2013, the Centers for Medicare and Medicaid Services (CMS) finalized the “Two-Midnight” Rule addressing when beneficiary hospitalizations are appropriate for inpatient payment under Medicare Part A. CMS adopted the “Two-Midnight” Rule to simplify the beneficiary...

In 2016, the Office of the Inspector General (OIG) published a report, “Vulnerabilities Remain Under Medicare’s 2-Midnight Policy”, summarizing the first findings of hospital billing patterns since the implementation of the Two-Midnight Rule. The results surprised...