CMS Two Midnight Rule

Why Should You Attend:

The presentation opens with an explanation and interpretation of the rule and includes exceptions. It explains the reason for the midnight designation based on the use of the midnight census to determine length of stay and provides an example of the calculation.

A discussion of the goal of the rule and questions about whether it has been achieved

A description of Medicare Parts A and B payment follows. History is then provided for context – why and how the rule developed including precursors of length of stay reduction and the move from in patient to ambulatory care as well as cast savings objectives.

Current requirements surrounding the Rule.

• The MOON (Medicare Outpatient Observation Notice)
• MOON components
• Who issues the MOON – implementation options
• How the Rule affects reimbursement or lack thereof for SNF (skilled nursing facility) stays as references in the MOON.

Role of the Case Manager in the ED.

Billing issues, Condition 44 code, billing for observation including criteria

Financial outcomes/implications of the rule for CMS, providers and consumers.

Example of costs to provider – code requirements for an observation unit in California

Medical outcomes of the Rule – quality of care, ability to obtain covered continued skilled care Case examples of observation vs inpatient

Controversy over the bill from cost shifting and consumer rights issues to quality of care concerns to the ability to truly differentiate status. Has the bill achieved its goals?

The purpose of this program is to familiarize the learner with an understanding of the 2 midnight rule as it applies to implementation within a facility including criteria and requirements. The financial outcomes of the rule both intended and unintended will be resented.

Attendees will be able to explain and interpret the 2 midnight rule

• Will be able to apply criteria to determine patient status
• Will understand and be able to discuss controversy surrounding the rule
• Will be able to discuss the impact of the rule on consumers

An understanding of the intent and interpretation of the rule will aide the participant in implementing a program to comply with the rule and if implemented can be used to review current practice for compliance. Having a historical context for the rule makes it easier to understand the strategy and anticipate governmental requirements.

The rule remains controversial with consumers and providers. Implementation of the MOON as well as staff training can mitigate misunderstanding and help to manage consumer expectations surrounding their care and its costs.

A general understanding of billing issues will be provided but this is not a billing specific program which is a specialized area requiring a separate webinar.

Areas Covered in the Webinar:

• Explanation
• Interpretation
• Historic context
• Patient notification requirement – MOON
• Staffing to accommodate the rule – CM role in the ED, staff training, issuance of above mentioned MOON
• Billing issues
• Financial implications for consumers and providers
• CMS goals/Intent
• Controversy
• Case Examples

Who Will Benefit:

• Case managers
• Social workers
• ED staff
• Patient representatives – those that deal with patient complaints and concerns
• Administrators/ managers of compliance, ED, patient financial Services
• Nursing staff for ED and observation units
• Nursing managers, administrators
• Admitting managers
• Insurance navigators

Laura Ostrowsky
President, NYC chapter of CMSA

Laura Ostrowsky RN, CCM MUP is the current president of the NYC chapter of CMSA and a Director on the national CMSA board. She teaches a CCM prep course with the Case Management Institute, works with Athena Forum, and writes andconsults on case management and related topics. Laura has published articles on Case Management in CMSA Today, Professional Case Management, Case in Point, The Patient Flow Journal and other periodicals. She regularly presents at national conferences including CMSA, the Patient Advocate Institute, NTOCC and others on topics ranging from case management, patient flow and payer provider collaboration to advocacy, collaborative practice and case management’s role in the changing health care environment.

Laura is a past Director of Case Management at Memorial Sloan-Kettering Cancer Center (1999-2019) and the 2012 CMSA Case Manager of the Year. Her program was been nominated by Case in Point for excellence in Utilization Management, Discharge Planning and Transitions in Care and awarded the patient Advocate Award. She created a patient advocacy program to assist patients in obtaining access to specialty care despite network restrictions. The program has been featured in articles in Advance for Nursing, The Wall Street Journal, Case in Point, and Case Management Monthly.

Laura holds a master’s degree in Health Planning and Policy from Hunter College.

Laura has 40 years of health care experience, including time as a staff nurse, QA Coordinator, Director of UR and QA, followed by directorships in CM at New York Presbyterian (NYP) and Memorial Sloan Kettering Cancer Center and providing educational presentations as part of the Genentech Speaker’s Bureau.

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