Temporary Pause of QIO Short Stay Reviews

On May 4, 2016, the Centers for Medicare & Medicaid Services (CMS) temporarily paused the Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations’ (QIOs) performance of initial patient status reviews to determine the appropriateness of Part A payment for short stay inpatient hospital claims. CMS took this action in an effort to promote consistent application of the medical review of patient status for short hospital stays.

What are short stay reviews?

Short stay reviews are reviews of claims for inpatient admissions to determine whether such claims were appropriately paid under Medicare Part A. Additional information related to short stay reviews is available here.

Who does short stay reviews?

At this time, BFCC QIOs are responsible for conducting initial short stay reviews. Recovery Auditors may also conduct short stay reviews, but only for those providers that have been referred to them by the BFCC-QIO as exhibiting persistent noncompliance with Medicare payment policies. 

When did BFCC QIOs start conducting short stay reviews?

 Beginning on October 1, 2015, the QIOs assumed responsibility for conducting initial patient status reviews of providers to determine the appropriateness of Part A payment for short stay inpatient hospital claims. These reviews were previously conducted by the Medicare Administrative Contractors (MACs). 

Why is CMS pausing short stay reviews?

CMS became aware of inconsistencies in the BFCC-QIOs’ application of the two-midnight policy for short hospital stay reviews, and on May 4, 2016, we temporarily paused short stay patient status reviews to give us time to improve standardization in the BFCC-QIOs’ review process.

CMS is requiring the BFCC-QIOs to re-review all claims they denied in their medical review process since October 2015 to make sure medical review decisions and subsequent provider education are consistent with current policy.  The current “pause” will allow time for the BFCC-QIOs to conduct these re-reviews.

When will the reviews resume?

The pause is temporary, and the claim reviews will resume after the BFCC-QIOs have completed retraining on the two-midnight policy, completed the re-review of previously denied claims, and performed any needed provider outreach and education. Many of these improvement steps have begun. CMS believes that BFCC–QIOs reviews will resume within 60-90 days. CMS will advise stakeholders when the pause is lifted.

What does this mean for claims that have already been denied?

CMS is working with the BFCC-QIOs to improve quality, including through educational sessions on practical application of the two-midnight policy, and is requiring that beginning June 6, 2016, that the BFCC-QIOs re-review all short stay patient status claims that were denied under the QIO medical review process. CMS urges hospitals to work with your BFCC-QIO (KEPRO at https://www.keproqio.com/ or Livanta, LCC, http://bfccqioarea5.com/and http://bfccqioarea1.com/)  to see if denied claims have been re-reviewed (undergone a final determination) before you appeal a claim denial.  Hospitals will receive a letter from the BFCC-QIO if denied claims are being re-reviewed, as well as a letter detailing the re-reviewed decisions.  If a hospital already submitted an appeal, then the BFCC-QIO will share its re-review findings with the appeals adjudicators to be taken into consideration during the appeal process. If upon re-review it is determined that the claim was incorrectly denied, the appeals adjudicators will issue revised determinations as necessary.

Click here to download a Policy Decision Guideline flowchart that will help guide the payment decision process.