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 and to allow time to improve standardization in the BFCC-QIOs’ review process.
On June 6, 2016, CMS required the BFCC-QIOs to re-review all short stay patient status claims that were denied under the QIO medical review process since the BFCC-QIOs began conducting these reviews on October 1, 2015.
The temporary suspension remains effective, and the BFCC-QIO short stay claim reviews will resume after the BFCC-QIOs have completed retraining on the inpatient admission policy, completed the re-review of previously formally denied claims, performed any needed provider outreach and education, and CMS validates the accuracy of the BFCC-QIOs’ performance of these activities. Many of these improvement steps have begun and are nearly complete. CMS will advise stakeholders when the suspension is lifted.
Q: What is CMS announcing today?
A: Today, CMS is announcing it has clarified the instructions for medical review of claims affected by the temporary suspension of the Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations’ (QIOs) performance of initial patient status reviews of acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities to determine the appropriateness of Part A payment for short stay inpatient hospital claims. Specifically, CMS is announcing that these reviews will be limited to a six-month look-back period from the date of admission and announcing that Medicare Fee-For-Service (FFS) claims that:
- Are outside the six-month look-back period and were formally denied (as defined below) are being removed from the provider sample for re-review and will be paid under Part A.
- Are outside the six-month look-back period and were not formally denied are being removed from the provider sample for re-review and will be paid under Part A.
- Are within the six-month look-back period and were not formally denied will be reviewed when we resume QIO reviews as per our sub-regulatory guidance at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html.
- Are within the six-month look-back period and were formally denied are being re-reviewed by the BFCC-QIO to determine whether the initial review decision was consistent with the two-midnight policy in effect at the time of the hospital admission.
For purposes of these instructions, “formally denied” is defined as meeting the following three criteria:
- The provider was sent an initial results letter by the BFCC-QIO; and
- The BFCC-QIO conducted and completed provider-specific education on claims in question; and
- The BFCC-QIO sent the provider a final results letter and the denial was sent to the MAC for effectuation.
Q: Why is CMS announcing a clarification to these instructions and limiting BFCC-QIO re-review to a six-month look-back period for claims impacted by the temporary suspension of the Beneficiary and Family Centered Care (BFCC) reviews?
A: Generally, when a Medicare Part A claim is denied by the BFCC-QIO, the provider has the opportunity to rebill under Medicare Part B within one calendar year after the date of service. The imposition of a six-month look-back period for claims impacted by the temporary suspension of the BFCC reviews is being implemented to help ensure that providers receiving denials for Part A claims have sufficient time to rebill under Medicare Part B.