Two-Midnight Rule Among Topics at NPAC 2024

As one of the co-chairs of the recent National Physician Advisors Conference (NPAC) in Coronado, Calif., I had a front-row seat to all that unfolded during a breathtaking spectacle of innovation and insight. Thanks to Dr. Hirsch for the shout-out, and as you are surely aware, it takes a village, so thanks as well to NPAC co-chairs Dr. Scott Ceule and Dr. Liz Quinn, and conference organizer Tracy Mitchell.

The conference, themed “Physician Advisor on Duty: Safeguarding Patients Amidst the Shifting Currents of Healthcare,” covered a vast spectrum of topics, including professional development and evolving roles for clinical documentation integrity (CDI) and physician advisors in the pediatric realm.

At NPAC 2024, attendees witnessed the convergence of cutting-edge technology meant to optimize healthcare. One of the standout features was the addition of the electronic health record (EHR)/analytics category, which showcased pioneering artificial intelligence (AI) solutions for CDI and utilization management promising to revolutionize healthcare on many fronts.

Moreover, the timeless appeal of events like the Observation Quiz Bowl and the Leadership Panel continued to engage both seasoned professionals and newcomers alike, fostering an atmosphere of collaboration and growth.

Several mainstage and track presentations at NPAC 2024 were dedicated to regulatory discussions, featuring lead industry figures like the keynote speaker: Marc Hartstein. Mr. Hartstein, renowned for his pivotal role in the development of the Two-Midnight Rule during his time at the Centers for Medicare & Medicaid Services (CMS), led discussions on Medicare issues. One intriguing question addressed was the role of the social determinants of health (SDoH) in determining inpatient status under the Two-Midnight Rule. According to regulation 42 CFR 412.3, the SDoH can indeed be considered, provided that appropriate documentation supports their impact on patient outcomes.

Another highlight was NPAC newcomer Richelle Marting’s presentation on Medicare Advantage (MA) regulatory changes and the resultant effects on the physician advisor and CDI. As a healthcare attorney specializing in managed care and reimbursement matters, I thought Marting shed light on compliance with general coverage and benefit conditions in CMS 4201-F, interpreting the dicey language surrounding appropriate internal coverage criteria for inpatient status determinations. Ms. Marting also provided ammunition to help avoid MA plan denials and pitfalls in the application of internal coverage criteria. Specifically, she pointed out that technically, the MA plans could use internal coverage criteria when there were not fully established official guidelines for an item or service, but they must be publicly accessible, and the MA plans have the burden to demonstrate that the internal criteria have clinical benefits to the patient that are highly likely to outweigh clinical harm. Ms. Marting also drove home that MA plans may not use InterQual or MCG criteria (or similar products) to change covered or payment criteria already established under traditional Medicare laws.

Dr. Hirsch also took the stage to provide an update on the 2024 regulatory landscape, discussing key provisions such as CMS 4201-F and the proposed rule 4204-P regarding condition code 44 and the loss of inpatient appeal rights.

NPAC 2024 was not just a conference; it was a testament to the dedication of physician advisors from across the country gathering together to share information while safeguarding patient care amidst the shifting currents in our current healthcare landscape.

Please join us next year in Chicago for NPAC in early April 2025.