Health Plan Policy Errs About CMS Two-Midnight Rule

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. 

Print Friendly, PDF & Email

Juliet Ugarte Hopkins, MD

Juliet B. Ugarte Hopkins, MD is Immediate Past President of the American College of Physician Advisors, Physician Advisor for Payor Peer-to-Peer Services for R1 RCM, Inc, and a member of the consulting teams for Phoenix Medical Management, Inc., Enjoin, CSI Companies, and Pediatric Resource Group via Velvet Hammer Physician Advising LLC. Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade and then developed the physician advisor role for case management, utilization, and clinical documentation at a three-hospital health system where she worked for nearly another decade. She is a member of the RACmonitor editorial board, author, and national speaker.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
2024 SDoH Update: Navigating Coding and Screening Assessment

2024 SDoH Update: Navigating Coding and Screening Assessment

Dive deep into the world of Social Determinants of Health (SDoH) coding with our comprehensive webcast. Explore the latest OPPS codes for 2024, understand SDoH assessments, and discover effective strategies for integrating coding seamlessly into healthcare practices. Gain invaluable insights and practical knowledge to navigate the complexities of SDoH coding confidently. Join us to unlock the potential of coding in promoting holistic patient care.

May 22, 2024
2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

HIM coding expert, Kay Piper, RHIA, CDIP, CCS, reviews the guidance and updates coders and CDIs on important information in each of the AHA’s 2024 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 15, 2024

Trending News

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 →

Happy World Health Day! Our exclusive webcast, ‘2024 SDoH Update: Navigating Coding and Screening Assessment,’  is just $99 for a limited time! Use code WorldHealth24 at checkout.

SPRING INTO SAVINGS! Get 21% OFF during our exclusive two-day sale starting 3/21/2024. Use SPRING24 at checkout to claim this offer. Click here to learn more →