The Centers for Medicare & Medicaid Services (CMS) has ordered the Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIOs) to re-review all claims they previously denied in their medical review process since last October. 

The announcement was posted via an updated memo dated June 6. In its posting, CMS said it was “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 … the BFCC-QIOs re-review all short stay patient status claims that were denied under the QIO medical review process.” 

CMS also stated that hospitals would receive a letter from their BFCC-QIO if denied claims were being re-reviewed, as well as a letter detailing the decisions that follow.

“If a hospital already submitted an appeal, then the BFCC-QIO will share its re-review findings with the appeals adjudicators (and they will 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,” CMS indicated.

The announcement of the re-review was also made during a CMS open door forum call yesterday, according to a source who listened to the call. 

The source, who spoke to RACmonitor on the condition of anonymity because she was not authorized to speak on behalf of her organization, said that the CMS central office told listeners “that if a re-review determines the claim was originally billed correctly, the claim will be sent to process for inpatient payment, with no action required by the provider.” When asked about claims that were pending initial review that had passed the rebilling deadline, listeners were instructed to “email them the question and they would post a Q&A once they had discussed the issue.” 

In a related development, 65 percent of respondents to a recent RACmonitor survey reported that they felt certain denials by QIOs were not appropriate.

“The fact that 35 percent of respondents found that the QIO denials were appropriate was intriguing to me,” said Ronald Hirsch, MD, vice president of Accretive Physician Advisory Services, in an email to RACmonitor. “That suggests to me that those hospitals are acknowledging that their processes are not sufficient and that they are letting through short stay inpatient admissions that were inappropriately admitted – and (these) should have been caught at some point prior to claim submission.” 

Hirsch, who has been monitoring the BFCC-QIO issue, went on to note that “these are admissions that were either not reviewed after admission and should have had the condition code 44 process applied, or should have been reviewed after discharge and self-denied and rebilled as inpatient Part B.”

According to Hirsch, if hospitals have the short stay admission review process hard-wired, and every short stay admission is reviewed prior to claim submission, then all denials should be viewed as inappropriate. 

In the same survey, 25 percent of respondents said that their denials were based on the QIOs auditing in accordance with the two-midnight rule, this on the heels of the May 4 announcement by CMS that it was suspending the BFCC-QIO review of short stays. The same survey also found that 81 percent of respondents had not received education from their BFCC-QIO. 

The same survey found that 33 percent of the respondents had between three and five short-stay claims denied, with 19 percent having six or more similar claims denied by the BFCC-QIOs.  

About the Author

Chuck Buck is publisher of RACmonitor and executive producer and program host of Monitor Mondays. 

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