SGR Fix Extends Moratorium on 2-Midnight Rule Enforcement

H.R.2 Restricts RAC Reviews of Patient Status Through September

Passage of the bill H.R. 2 Medicare Access and CHIP Reauthorization Act (MACRA) last night by the U.S. Senate extended many programs, including a slight extension of the Medicare Administration Contractors (MAC) so-called “Probe and Education” program, as well as the moratorium on post-payment patient status reviews of claims filed subject to the 2-Midnight Rule since October 1, 2013.

What really changed vis-à-vis the RAC?

Click the image for the PDF of H.R.2, aka MACRA

The changes made by MACRA (p. 249 in the PDF, under Section 521) involve H.R. 4302 Protecting Access to Medicare Act of 2014 (aka PAMA, Public Law 113–93; 42 U.S.C. 1395ddd note, see p. 5 in the PDF), and change the language to finally read as follows (changed language noted with {} brackets and red text):

SEC. 111. EXTENSION OF TWO-MIDNIGHT RULE.
(a) CONTINUATION OF CERTAIN MEDICAL REVIEW ACTIVITIES.—
The Secretary of Health and Human Services may continue medical review activities described in the notice entitled ‘‘Selecting Hospital Claims for Patient Status Reviews: Admissions On or After October 1, 2013’’, posted on the Internet website of the Centers for Medicare & Medicaid Services, {through the end of fiscal year 2015} for such additional hospital claims as the Secretary determines appropriate.

(b) LIMITATION.—The Secretary of Health and Human Services shall not conduct patient status reviews (as described in such notice) on a post-payment review basis through recovery audit contractors under section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)) for inpatient claims with dates of admission October 1, 2013, through {September 30, 2015}, unless there is evidence of systematic gaming, fraud, abuse, or delays in the provision of care by a provider of services (as defined in section 1861(u) of such Act (42 U.S.C. 1395x(u))).

{(c) CONSTRUCTION.—Except as provided in subsections (a) and (b), nothing in this section shall be construed as limiting the Secretary’s authority to pursue fraud and abuse activities under such section 1893(h) or otherwise.}

Click the image for the PDF of H.R. 4302, aka PAMA

Click the image for the PDF of H.R. 4302, aka PAMA

According to the limitation in (b), RACs are now specifically prohibited, for a time, from such post-payment reviews, absent evidence of gaming, fraud or intentional delay of service for the sake of increased reimbursement.

Related Posts Plugin for WordPress, Blogger...
This entry was posted in Academy Blog and tagged , , , , , , , , , . Bookmark the permalink.