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Inpatient status reviews of short stays have resumed, according to an announcement made yesterday by the Centers for Medicare & Medicaid Services (CMS).

CMS noted that the Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIOs) would “resume initial patient status reviews of short stays in acute-care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities to determine the appropriateness of Part A payment for short-stay hospital claims.”  

“As a reminder, CMS had halted these reviews on May 4 when it was brought to CMS’s attention by multiple providers that the BFCC-QIOs (KEPRO and Livanta) were interpreting the rule incorrectly and denying short-stay inpatient admissions inappropriately,” Ronald Hirsch, MD said in a statement to RACmonitor. “This followed the surprising audit of admissions that dated back much prior to the initially announced Oct. 1, 2016 eligible admission date.”

Hirsch also said that after halting the reviews and instructing the QIOs to receive additional education, once auditing resumed, CMS then imposed a six-month lookback period when it was pointed out to the agency during an open door forum call that a denial of an admission from nine months prior left no time in the one-year timely filing limit for Part B rebilling.

“In the announcement, CMS also made it very clear that they were issuing no new guidance to the QIOs, emphasizing, it appears, the contention that it was QIOs that were at fault in this audit delay,” Hirsch said. “CMS also sought to reassure providers who have gone through almost three years of on-again, off-again audits, where accuracy was no better than a coin flip, by stating that they would continue to provide oversight of the QIOs by re-reviewing a sample of BFCC-QIO completed claim reviews each month, monitoring provider education calls, and responding to individual provider inquiries and concerns.”

Hirsch said that CMS even took the unusual step of publicizing the use of the open door forum email address (ODF@cms.hhs.gov) as a resource for providers to submit questions. Hirsch assumed that in doing so, CMS wanted providers to notify them if the QIOs were unable to properly apply the “two-midnight rule” in their audits.  

“As a reminder, the QIOs may only refer hospitals to the recovery auditors (RAs) who are ‘exhibiting persistent noncompliance with Medicare payment policies,’” Hirsch added. “(This is) including, but not limited to having high denial rates and consistently failing to adhere to the two-midnight rule (including repeatedly submitting inappropriate inpatient claims for stays that do not span one midnight) or failing to improve their performance after QIO educational intervention.”

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Chuck Buck is the publisher of RACmonitor and the executive producer and program host of Monitor Monday.

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Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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