RACs and The Over Two-Midnights Rule

Event Information
Product Format
Prerecorded Event
90 minutes
Product Description

Will the New ‘Over 2-Midnights’ Rule Actually Resolve the Issue of Proper Inpatient Admissions?

The new CMS ‘Over 2-Midnights’ rule couldn’t see full implementation due to delay by the Congress; however, some form of this rule has been implemented. The main objective of this new rule is to address the challenge of proper inpatient admissions versus placing the patient into outpatient observation. The RACs have made short-stay inpatient admissions a major issue by challenging significant numbers of cases.

Hospitals have, in turn, appealed many of these cases which have caused a significant backlog of cases at the appeals level. A fundamental issue is how the RACs and other auditors review these cases and the guidelines for auditing. While prospective auditing should be the norm, often the auditors will review the entire case and use retrospective auditing.

This audio conference focuses on the nuts and bolts of the new CMS ‘Over 2-Midnights’ rule. Expert speaker Duane C. Abbey, Ph.D. will answer some pertinent questions in this training session, such as:

  • What is the current status of the RAC program?
  • Why are there so many appeals at the ALJ/MAC level?
  • How should physicians and hospitals be working to establish appropriate inpatient admissions?
  • What is all the fuss about the ‘Over 2-Midnights rule’?
  • What is the difference between the ‘24-Hour’ Rule and the ‘Over 2-Midnights’ rule?
  • Where does Condition Code 44 fit into the picture?
  • What is the difference between ‘retrospective’ auditing and ‘prospective’ auditing?
  • Will the new ‘Over 2-Midnights’ rule actually resolve the issue of proper inpatient admissions?
  • Why is this new rule so controversial?
  • What are the findings in cases such as the O’Connor Hospital Ruling?
  • How Has CMS Reacted To the O’Connor Hospital Ruling?
  • Just What Constitutes an Inpatient Admission?
  • What do physicians need to document in order to justify hospital services?
  • How does Utilization Review fit into this overall inpatient admission process?

Session Objectives: 

  • Review Current RAC Activities
  • Discuss the Enormous Backlog of Appeals at the ALJ/MAC level
  • Discuss One of the Main Issues Causing the Backlog – Hospital Inpatient Admissions vs. Observation Services
  • Discuss Proper Physician Documentation for Inpatient and Observation Services
  • Review the ‘Over 2-Midnights’ Rule and the Sub-regulatory Guidance Being Issued
  • Discuss the issue of what constitutes an inpatient admission
  • Review physician requirements for inpatient admissions versus outpatient observation admissions
  • Review inpatient admission criteria including CMS’s new ‘Over 2-Midnights’ rule
  • Know the difference between prospective and retrospective auditing
  • Appreciate how the Medicare interpretation of Condition Code 44 is different from private payer interpretations and usage
  • Briefly review the O’Connor Hospital Ruling from the Medicare Appeals Council
  • Discuss the Utilization Review Committee involvement in observation and for changes in inpatient status after the patient’s discharge

Session Agenda: 

  • Overview
    • Objectives of the RAC Program
    • Short-Stay Inpatient Admissions
    • CMS Rules and Sub-regulatory Guidance
  • RAC Status
    • Appeals Process
    • Current Backlog of Appeals at the ALJ/MAC Level
  • Major Concern for RAC Denials of Inpatient Admissions
    • What Constitutes an Inpatient Admission?
    • How Inpatient Is Different From Observation
    • The ‘Over 2-Midnights’ Rule
      • Sub-regulatory Guidance
      • Medical Staff Training and Guidance
      • RAC Involvement
  • Auditing for Inpatient vs. Observation Admissions
    • Retrospective
      • Review Whole Case
      • Outcome Oriented
    • Prospective
      • Review Decision Making Process
      • Final Disposition Not Relevant
  • Inpatient vs. Outpatient Status
    • Inpatient Admission Process
    • Medical Necessity Documentation
    • Standardized Inpatient Criteria
    • Compliance Issues
    • Payment Documentation
    • RAC Involvement
    • CMS’s Fundamental Premise
  • Related Issues
    • O’Connor Hospital Ruling
    • Utilization Review
    • Condition Code 44
  • Case Studies and Exercises
  • Sources for Additional Information

Prerequisites for Participating: A general understanding of health care compliance, the RACs, the OIG Work Plan and coding, billing and reimbursement compliance.

Who should attend

Chief Compliance Officers, CBR Compliance Officers, Healthcare Auditors, Healthcare Compliance Personnel, Chargemaster Coordinators, Billing and Claims Generation Personnel, Patient Financial Management Personnel, Cost Accounting Personnel, Cost Report Personnel, Financial Analysts, Managed Care Contract Personnel, Revenue Enhancement Personnel, Chief Financial Officers, Chief Compliance Officers, Financial Planners, Clinic Managers/Administrators Utilization Review Personnel, Medical Staff Organization Personnel, Physicians, Non-Physician Practitioners, All Other Hospital Personnel Interested in Compliance and RAC Activities


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About Our Speaker

Duane Abbey Hospital Coding & Compliance Expert

 Duane C. Abbey, Ph.D. is a management consultant and president of Abbey & Abbey, Consultants, Inc., which specializes in healthcare consulting and related areas. Duane earned his graduate degrees at the University of Notre Dame and Iowa State University and has more than 20 years of experience as a consultant. He performs various types of financial analysis involving business structuring, organizational development, enrolment and other financially related concerns of organizations....   More Info
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