What is the 72 Hour Rule and How does it Apply to Medicare?

The 72 hour rule is one of the factors that make up the Medicare Prospective Payment System. It states that should a Medicare beneficiary need hospital treatment within 72 hours of a physician visit, diagnostic treatment or receiving medical services, it counts as a single claim.

The two treatments should not be billed separately, but as one combined bill.

Examples of services that count towards the 72 Hour Rule:

Lab treatment
CT scans
Osteopathic treatment
Radiology treatment

Exclusion of Other Services

In order to understand the 72 Hour Rule, it is essential to understand the difference between ‘diagnostic’ and ‘other’ services. In order for the 72 Hour Rule to be effective, the diagnostic service must be related to the patient’s complaint; otherwise it must be billed separately.

One such example could be that a person undergoes a liver transplant, when they have previously received diagnostic treatment for high blood pressure. There is a remote likelihood of the two being related, and thus it would be billed as two separate treatments.

Had this person received dialysis treatment 72 hours or less prior to surgery, then they would receive a single Medicare billing as per the 72 Hour Rule.

Patient Rights

You must have Medicare Part A coverage to qualify for the 72 hour benefit. If you have any questions about which Medicare insurance plan would best suit your needs, fill out the form at the bottom of this page and one of our representatives will contact you.

Medicare Appeals and Grievances

When you are enrolled in an original Medicare plan, you have the right to appeal if you feel you are being treated unfairly. The first 72 hours after a hospital admission are crucial to your Medicare claim. Find out how in this comprehensive guide.

You have appeal rights for Managed Care plans and Prescription Drug plans. You are also protected when you are in the hospital whether you are with the Original Medicare plan or the Managed Care plan.

You have the right to get all the hospital care you need, and any follow up care required.
You also have options if you think the hospital is making you leave too soon.

For any questions regarding these matters you can call 1-860-MEDICARE.

If you inquire from Quality Improvement Organization (QIO) to analyze your case, you have chances of remaining in hospital free of cost. You cannot be forced to leave the hospital before the review is completed by a QIO.

Healthcare Compliance Plan For Hospitals

There is a three day window where Hospitals can collect on unrelated work done for a patient as long as the 72 hour window applies. Diagnostic services performed within three days prior to hospital admission can be bundled into the DRG payment.