Contrary to the belief of some, the rule remains alive and well.
EDITOR’S NOTE: The rumor mill was churning recently regarding news from a Wisconsin health plan that reportedly was discontinuing adherence to the contentious two-midnight rule of the Centers for Medicare & Medicaid Services (CMS), believing that CMS was, too.
Sometimes, a simple question can open a door to what feels like The Twilight Zone. This happened to me late last week when I received an update from my health system’s contracting office.
Earlier in the week, I had asked my contact in the office to investigate if any of our contracted managed Medicare plans had updated policies supporting use of the two-midnight rule. It wasn’t likely, but I figured we might as well make sure nothing had come up recently. While plans regularly send us policy updates, they are often convoluted, and it can be difficult to recognize important changes.
Her reply a couple of days later indicated that some plans had replied that no, they were not following the Medicare two-midnight rule. Others she was still waiting to hear back from, but one in particular, Security Health Plan, responded with a link from their administrative manual:
Their policy, titled “Two Midnight Rule,” which was “last updated on January 24, 2019,” made my jaw drop at the first sentence:
“In line with the recent Centers for Medicare & Medicaid Services suspension of the two-midnight rule, effective immediately, Security Health Plan will also suspend implementation of this rule.”
What’s that, now? For a brief moment, I thought perhaps I was not the well-informed physician advisor I thought I was. Quickly, I dismissed that thought, deciding that there was no way I could have missed such a major development as CMS’s abandoning the two-midnight rule. What the heck was going on?
I called the 800 number listed in the policy to address questions, and eventually, I was connected with the individual who originally sent the link in response to my contracting office’s question. “CMS never suspended the two-midnight rule,” I said. “What’s this policy about?”
While the individual on the other line was unable to answer my questions, I was told someone else would call me back to discuss.
While waiting, I looked around the plan’s website and learned a bit about the payor. Originally founded in 1971 as the Greater Marshfield Community Health Plan, in 1986 it evolved into Security Health Plan, and it is now part of the Marshfield Clinic Health System in Wisconsin. They describe themselves as “a not-for-profit health maintenance organization” offering “a variety of health-insurance options for employer groups and individuals and families of all ages and income levels.”
I called back after the weekend passed and asked when I might be able to speak to someone who had knowledge about the creation of the policy. I was told that someone would call me back later in the day if they could, but I ended up getting another call from my original contact.
Unfortunately, the policy folks didn’t have time to discuss the situation, but they wanted to pass along the message that “CMS was going back and forth about continuing the two-midnight rule, and we at Security Health Plan decided we would not follow (it).” I responded that this was not the case; CMS had never recently indicated it was considering abandoning the two-midnight rule. This was met with assurance that my point would be passed along.
I’ve come away from this experience without any good answers. But I will close with noting that boy, this subject matter is challenging! And not just for patients, hospital administrators, case management staff, and providers. Clearly, even health insurance plans can become mixed up! Because in all honesty, I truly believe this policy was the result of an honest mistake. Someone, somewhere within the plan found a confounding and cryptic communication from CMS and misunderstood what they read. From there, decisions were made and posted as policy.
I get it. We all get it. I just hope they make the adjustment online soon, so others don’t become similarly confused.
Welcome back everybody after the holidays. As a CPA, I have always been uncomfortable when the word “Audit” is used to describe activity since the term
I am going to start 2026 by doing something I rarely do, and that is compliment an insurance company, and United Healthcare at that. As you
Please log in to your account to comment on this article.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
As AI reshapes healthcare compliance, the risk of biased outputs and opaque decision-making grows. This webcast, led by Frank Cohen, delivers a practical Four-Pillar Governance Framework—Transparency, Accountability, Fairness, and Explainability—to help you govern AI-driven claim auditing with confidence. Learn how to identify and mitigate bias, implement robust human oversight, and document defensible AI review processes that regulators and auditors will accept. Discover concrete remedies, from rotation protocols to uncertainty scoring, and actionable steps to evaluate vendors before contracts are signed. In a regulatory landscape that moves faster than ever, gain the tools to stay compliant, defend your processes, and reduce liability while maintaining operational effectiveness.
Get clear, practical answers to Medicare’s most confusing regulations. Join Dr. Ronald Hirsch as he breaks down real-world compliance challenges and shares guidance your team can apply right away.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
