CMS clarifies look-back rules for some short-stay claims


The Centers for Medicare & Medicaid Services has clarified lookback rules for some short-stay inpatient hospital claims.

The agency said the clarification revolves around claims involving the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs), which were created to improve the quality of care delivered to Medicare beneficiaries.

In June, CMS asked the BFCC-QIOs to re-review any denied claims since reviews began last October. It also paused all other reviews related to short-stay claims.


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Reviews of short-stay hospital claims have been a matter of fierce controversy since CMS began introducing audits and clawbacks about seven years ago. Hospitals have regularly fought such clawbacks under the five-step appeals process available to them, clogging up federal administrative law courts and putting pressure on the Medicare program to make changes. As a result, the agency in 2014 offered to settle many claims directly with acute care hospitals for 68 cents on the dollar.

Regarding clarifications, CMS said that all claims reviewed and rejected outside of the look-back period will be paid under Part A. All claims within the period that have not yet been formally denied will be re-reviewed after it lifts the temporary suspension on ongoing reviews.

"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," CMS said.

- read the CMS announcement

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