Throughout 2013, the Centers for Medicare & Medicaid Services (CMS) published several communications about inpatient admissions with emphasis on admissions that cross "two midnights."
CMS has indicated, for example, that Original Medicare will not focus on inpatient admissions that cross two midnights when determining whether to review for medical necessity and has indicated that Original Medicare is adopting a two-midnight presumption. CMS has also clarified that coverage of inpatient admissions is limited to those admissions that were determined to be medically necessary by a review of the facts of the situation.
When reviewing to determine whether an admission was medically necessary, Humana's MA policy is to adhere to Original Medicare's requirements, such as the requirement for complete and valid certifications and orders of admission.
When reviewing a claim for an inpatient admission for medical necessity, Humana MA plans will take into consideration all available relevant facts, including whether the stay crossed two midnights and whether at the time of the order of admission the ordering health care provider reasonably believed that inpatient admission was medically necessary. If an inpatient stay crossed two midnights, that fact is significant, but is not sufficient to establish medical necessity.
Humana's policy is that an inpatient claim can be reviewed for medical necessity even if it crosses two midnights. Health care providers should always assume that Humana Medicare Advantage (MA) plans may review a claim for medical necessity.