Some hospitals are having a hard time letting go of admission screening tools, but they add very little value for Medicare fee-for-service patients under the two-midnight rule and may have a compliance backlash, some compliance experts say. When time receiving hospital services became the determining factor for Part A coverage of medically necessary inpatient admissions under the two-midnight rule, admission screening tools lost their usefulness, as CMS explained in the 2014 inpatient prospective payment system regulation that implemented the two-midnight rule and subsequent guidance, they say.

But admission screening tools, such as InterQual and MCG (formerly Milliman), “are so ingrained into utilization review it’s almost like we can’t imagine living without them,” says Joseph Zebrowitz, M.D., co-chief executive officer of Versalus Health in Newtown Square, Pa.

Some hospitals also think the Medicare conditions of participation require 100% review of inpatient admissions as part of the utilization review (UR) process, but that’s not true either, they say. “The conditions of participation state that the UR process may be performed through sampling,” Zebrowitz says (see 42 CFR 482.30(c)(3)). He says 100% admission reviews only are required for outlier cases—day outliers with a length of stay greater than 20 days and cost outliers (see paragraph e of 42 CFR 482.30(c)(3)).