​The Centers for Medicare and Medicaid Services (CMS) has given its quality improvement organizations (QIOs) the green light to resume their review of Medicare claims for inpatient stays shorter than a span of two midnights. The announcement comes after CMS addressed hospital concerns about the review process. The QIO reviews of short stays under the so-called two-midnight rule resumed on September 12, 2016, CMS said in a question-and-answer brief announcing the end of a four-month suspension of the reviews. CMS is conducting the reviews to ensure that it is not reimbursing providers for claims that do not adhere to the rule, which specifies that the agency reimburse only for claims with lengths of stay greater than two midnights. The QIOs also review on a case-by-case basis the appropriateness of payment for claims of stays that do not adhere to the two-midnight rule by looking for documentation in the medical record from the admitting physician that the patient required inpatient care. CMS paused its short-stay claims review after the American Hospital Association expressed concerns that the reviews were being conducted inconsistently. CMS said it lifted the temporary suspension after retraining its QIOs on its two-midnight claims review procedure, completing a re-review of claims that had been previously denied, performing provider outreach on its two-midnight policy, and taking other steps outlined by the agency. The reviews apply to inpatient claims submitted by acute care hospitals, long-term care hospitals, and inpatient psychiatric facilities. The claims reviews are conducted by two QIOs.

HRC Recommends: Risk managers and compliance officers should review the process that CMS's QIOs follow to review short-stay hospital claims and should be familiar with the medical record documentation that is necessary to support inpatient stays that are exceptions to the two-midnight rule. They should conduct medical record audits to review the documentation of patients with short stays, identify any documentation lapses, and educate providers to help them adhere to the necessary documentation requirements.