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 policies regarding patient status for short hospital stays and to allow time to improve standardization in the BFCC-QIOs’ review process.
Q: What is CMS announcing today?
A: CMS is announcing that, effective September 12, 2016, BFCC-QIOs will 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.
Q: Why is CMS ending the temporary suspension of the BFCC-QIO short stay reviews?
A: CMS is lifting the temporary suspension of short stay reviews because:
- The BFCC-QIOs successfully completed re-training on the Two-Midnight policy;
- The BFCC-QIOs have completed a re-review of claims that were previously formally denied;
- CMS examined and validated the BFCC-QIOs peer review activities related to short stay reviews;
- The BFCC-QIOs performed provider outreach on claims impacted by the temporary suspension; and
- The BFCC-QIOs initiated provider outreach and education regarding the Two-Midnight policy.
Q: Will there be oversight of the BFCC-QIOs review of short stay inpatient hospital claims?
A: Yes. CMS will continue its oversight efforts 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. Providers may send questions to the CMS Open Door Forum Mailbox at ODF@cms.hhs.gov.
Q: Has CMS made any changes to the BFCC-QIO guidance under which they will perform these reviews?
A: No. The BFCC-QIOs will continue to follow the guidance entitled, “Reviewing Short Stay Hospital Claims for Patient Status: Admissions On or After January 1, 2016,” which can be found at: https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review/inpatienthospitalreviews.html.
Q: What types of outreach and education are the BFCC-QIOs using to educate providers?
A: The BFCC-QIOs were directed to use comprehensive outreach and communication approaches (i.e. website, newsletter, one-on-one training, and town hall type events) to continue to educate providers on when payment under Medicare Part A is appropriate under the Two-Midnight policy. BFCC-QIOs are required to educate providers using quality improvement core principles that facilitate continuous learning and promote greater provider understanding of the appropriate application of the Two-Midnight policy in accordance with the revisions in the CY 2016 OPPS Final Rule (CMS-1633-FC): https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1633-FC.html