As of January 1, 2024, Medicare Advantage and Part D final rule regarding access to care for Medicare beneficiaries is fully applicable, a process which was first set into effect in June 2023. Per the Report in Brief of the Office of Inspector General from April 2022, CMS audits of Medicare Advantage plans found that denials had been issued in cases where the requests for care met Medicare guidelines, thus denying or delaying access to necessary care. This updated rule provides stronger guidance for providers to support their determinations in that the Medicare Advantage plans will be held to the following:
- Observing the Medicare Inpatient Only list
- Following the Two-Midnight rule
- No longer able to retrospectively deny inpatient admission status when unforeseen events occur, such as Medicare beneficiary death, unanticipated rapid improvement, or leaving against medical advice
Medicare Program Integrity Manual Chapter 6 outlines that Medicare Advantage plans should not focus review efforts on admissions that meet the Two-Midnight rule. Plans should instead presume that these stays are reasonable and necessary (barring evidence of repeated abuse by facilities, such as delaying care to achieve greater than a Two-Midnight stay). However, health systems should not be less diligent in documenting the need for this care.
It will continue to be vital that providers validate their inpatient admission determinations and overall risk assessment in the medical record:
- What concerns they have
- Plans for testing/treatment
- Estimated length of stay
- Comorbidities or other risk factors that place the beneficiary at a higher risk
Additionally, it is important to ensure that admission and need for ongoing stays are documented based on medical necessity, not concerns regarding social issues, patient preference, etc. Having a clear understanding of when the two-midnight stay begins–which is the point in time when the patient first begins receiving symptom-related care post-triage–not when the actual order is written.
MCG Health guidelines for inpatient admission can be another measure of validation that the patient meets the criteria. The onus, as always, is on the facility and providers to understand what CMS says and requires in order to appeal any denials:
- Know the timeline of the patient from triage to treatment-based care
- Know the overall case in terms of severity of illness, treatment, comorbid conditions, and/or complicating factors
- Make sure the hard work being performed for the care of the patient is documented and be prepared to justify the patient’s need for inpatient admission
If you have any questions regarding Medicare Advantage, please contact a Forvis Mazars consultant today.