CMS resumes some short-stay payment reviews


The Centers for Medicare & Medicaid Services (CMS) has resumed reviewing payments for short hospital stays involving Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) after suspending them for more than four months.

The agency posted on its website that it had resumed the reviews beginning on Sept. 12.

CMS had suspended the short-stay payment reviews on May 4 “to promote consistent application of the medical review policies regarding patient status for short hospital stays and to allow time to improve standardization in process.” It said that personnel at the BFCC-QIOs have been successfully retrained as to the two-midnight rules for inpatient admissions, as well as conducting outreach and education to affiliated providers.

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The two-midnight rule was implemented to create a bright line as to what should be an observation stay for Medicare patients--which is paid on an outpatient basis and excludes nursing home coverage for patients after the hospital stay ends--versus an inpatient hospital admission.

The agency issued clarifications for the short-stay reviews back in August. It decided to suspend the process because there had been some issues as to the lookback timeframe as to when BFCC-QIOs could rebill rejected Part A claims under Part B. All claims within the period that have not yet been formally denied will be re-reviewed by CMS now that the suspension has been lifted.

Short-stay reviews have long been a bone of contention for hospitals, which promptly filed numerous appeals, flooding the system that handles reviews. That in turn led to a drop in the recouping of claims payments from recovery auditor contractors (RACs), which put pressure on CMS to try and revamp the claims review process to some extent. CMS offered to settle the backlog of appealed claims for 68 cents on the dollar in 2014.

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