Here’s an update on the two-midnight rule and provider audits

As of July 31, 2017, Blue Cross Blue Shield of Michigan implemented a prior authorization request process to determine coverage for inpatient care. Using evidence-based criteria, this process focuses on reducing costly overutilization of inpatient services and admissions while providing safe, high-quality care. The prior authorization request process, outlined in the Medicare Plus Blue^SM PPO manual, takes precedence over the original Medicare coverage determination process and the “two-midnight” rule.

As such, Provider Audit, through HMS^®, a Blue Cross vendor, is not currently conducting short-stay or place-of-service audits. We’re still conducting documentation and compliance audits of valid inpatient orders and Medicare Outpatient Observation Notice, or MOON, forms. In accordance with Centers for Medicare & Medicaid Services and Blue Cross rules, providers should follow documentation and compliance requirements closely to avoid possible recovery of funds during claims processing and post-payment audits.

We’ll continue to audit for procedures on the CMS inpatient-only list. However, because CMS has deferred the enforcement of joint replacement surgery reviews for two years, Provider Audit has no plans to review those admissions in the near term.

If you have any general questions about the audit process, reach out to your provider consultant.

Also, we’re modifying the provider appeals time frames for non-hospital facility and professional providers. For information, see this article.