During the Recovery Audit Contractor (“RAC”) demonstration program, a significant number of the claims denied were denied for the reason that an inpatient hospital admission was not medically necessary. The RACs regularly based these denials not upon published Medicare guidance, but based upon the criteria of private companies, such as InterQual.
In an effort to provide clarification regarding Medicare criteria regarding inpatient hospital admissions, the Centers for Medicare & Medicaid Services (“CMS”) recently published a Special Edition MLN Matters article entitled, “Guidance on Hospital Inpatient Admission Decisions.” The MLN Matters article cites to guidance published in the CMS Internet-Only Manuals, which sets forth the requirements for inpatient hospital services.
• The Medicare Program Integrity Manual, Chapter 6, Section 6.5, clarifies that, in determining whether an inpatient admission is medically necessary, a CMS reviewer should use the hospital’s admission criteria; invasive procedure criteria; CMS coverage guidelines; published CMS criteria; and practice guidelines that are well-accepted by the medical community.
• CMS also has published guidance regarding inpatient hospital admissions in the Medicare Benefit Policy Manual, Chapter 1, Section 10, which generally defines an inpatient as follows: “An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as an inpatient with the expectation that he or she will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight…”
For more information regarding the RAC program, please visit the RAC page of The HLP website, or call Abby Pendleton, Esq. or Jessica L. Gustafson, Esq. at (248) 996-8510.