The 48-Hour Rule Explained

What You Need to Know

Hospitals receive a global payment for all services and items delivered during an inpatient stay. Medicare therefore presumes that any device - including a prosthesis or brace - dispensed while the recipient is still a hospital patient is part of that global payment. Stated slightly differently, Medicare's general expectation is that this item will not get billed to Medicare Part B, which only covers outpatient care.

The 48-Hour Rule is a limited exception to this presumption. It permits the delivery of a prosthetic or bracing device to a hospital patient pre-discharge, but only if all of the following 8 criteria are satisfied:

1. The prescription has an initial date of need that pre-dates the patient’s discharge;
2. You deliver the item to the patient in the facility only for fitting or training (i.e., they cannot use the item in the hospital);
3. You deliver the item to the patient in the facility 48 hours or less from their discharge;
4. You ensure that the patient takes the item home or you deliver it to their home on the discharge date;
5. You are not trying to save the hospital the cost of paying for something already included in its global fee;
6. You don’t claim payment for the item for any day before discharge;
7. You don’t bill patients for delivery costs if you deliver to their home on the discharge date; and
8. The patient is discharged to their home - not to another inpatient facility or SNF.

If any one of these requirements isn't satisfied, you should be billing the hospital directly for the item you've provided the patient.

What this Means for You

Non-compliance with the 48-Rule is a serious matter. If Medicare determines that you are charging Part B of the program for items that should've been part of the Part A hospitalization/global payment, you can face significant financial and other penalties. Widespread and non-compliant use of the 48-Hour Rule to justify billing Medicare Part B can lead to charges that you are engaging in a systematic kickback scheme with the hospital, as your actions are removing a cost from the hospital's balance sheet, thereby improving its profitability. Serial wrongful use of the 48-Hour Rule will likely lead investigators to infer that your intent was to secure ongoing referrals from the hospital by relieving it of a charge it should have been paying in violation of the federal Anti-Kickback Law.

As a result, the starting point for 48-Hour Rule compliance is to remember that it is a limited exception to a general rule stating that items dispensed to an inpatient are part of the global payment made to the hospital. When the 48-Hour Rule doesn't apply, you must bill the hospital directly for the item delivered to the inpatient prior to discharge.

In those instances where the 48-Hour Rule does legitimately apply, your records should clearly state that the prosthesis or brace was provided to the patient purely for training purposes - not for use in the hospital pre-discharge. You should document the specific training you provided in detail. Lastly, before billing Medicare Part B, you should always confirm the patient's discharge date. Even if you delivered an item in good faith based on your understanding that the patient was going to be discharged within 48 hours, if unanticipated circumstances led to the patient not getting discharged until more than 48 hours later, you cannot rely on this rule to bill Medicare Part B. In that instance, the discharge delay means that you no longer satisfy all 8 elements of the 48-Hour Rule. You would therefore have to instead bill the hospital directly for payment.