In August of this year, the Centers for Medicare & Medicaid Services (CMS) announced revisions to Chapter 5 of the Quality Improvement Organization (QIO) Manual, which addresses quality-of-care reviews.

According to CMS, “A Quality Improvement Organization (QIO) is a group of health-quality experts, clinicians and consumers organized to improve the care delivered to people with Medicare.” CMS continues to state that “QIOs work under the direction of CMS to assist Medicare providers with quality improvement and to review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.” 

With the definition and purpose of QIOs clearly stated, the most important changes announced last month include the following three points according to KEPRO, a Medicare QIO under contract with CMS:

  • Providers will have 14 days (they’re currently allowed 30 days) to send in the medical record when a quality-of-care complaint is filed. Because of these tightened time frames, KEPRO encourages providers to “fax medical records to KEPRO rather than sending them via mail.
  • After the medical records are received, KEPRO has 30 days to complete the review. Providers that wish to provide a response when they receive an inquiry from KEPRO will also have a shortened time frame, which will be noted on the inquiry letter.
  • Medicare beneficiaries, or their representatives, will have the opportunity to request a second review if they disagree with the original findings, similar to the current process in place for providers.

Particularly concerning is the drastic reduction in the amount of time allowed for providers to respond to a quality-of-care complaint.

Tighter deadlines increase chance of errors 

Currently allowed 30 days, providers will soon have less than half that time—just 14 days—to send the proper information needed to support the claim and rebuff the complaint. Providers are encouraged to fax this information, as the new truncated timeline offers little in the way of a buffer zone should items get held up in the mail.

Providers will also have a reduced amount of time to submit any follow-up communication to the QIO. And it appears as though providers may not be told what this new deadline is until they receive the QIO’s initial review (which the QIO still has 30 days to complete). 

Not only are the truncated deadline changes troubling, especially for providers already in a time crunch, they also seem to be diametrically opposed to the end goals of the Electronic Submission of Medical Documentation (esMD) program. CMS should be moving toward electronic submission, not encouraging providers to replace one form of paper (mail) with another (fax).

What about esMD?

The esMD system, which allows providers to respond to documentation requests electronically via PDF files, would certainly help streamline the audit process. And once administrative costs—photocopying, faxing and mailing, for example—are lessened, more hospitals are likely to pursue appeals. Other benefits of esMD include elimination of disputes about lost documentation and quicker turnaround times. CMS reports that the payment turnaround for providers using esMD is six days versus three weeks for those using a paper process. 

During Phase 1 of esMD, which went live on Sept. 15, 2011, providers still receive medical documentation requests via paper mail, but have the option to electronically send medical documentation to the requesting review contractor. During Phase 2 of esMD, providers will receive electronic documentation requests when their claims are selected for review. CMS plans to go live with esMD Phase 2 “in the future,” and has yet to name a specific launch date.

This nebulous status of esMD coupled with QIO’s suggestion to use fax machines certainly raises important questions about the state of esMD.

Full, multidirectional submission preferred

It would make more sense to postpone drastically cutting time restrictions until systems are in place that would allow all QIOs to receive provider information electronically, and not via fax or contractor portals. A cart-before-horse mentality will not get us to full esMD implementation any faster. In fact, these new restrictions seem to fly in the face of the big picture, which frames full, multidirectional electronic submission of data as an integral part of a patient-centric, quality-based healthcare system.

More QIO News 

Also, starting today, Oct. 1, 2015, QIOs will conduct their first line of patient status reviews of providers to determine the appropriateness of Part A payment for short-stay inpatient hospital claims. If the QIOs see abusive patterns, they have the ability to send the results of those reviews to the Recovery Audit Contractors (RACs) for follow-up. These reviews were previously conducted by the Medicare Administrative Contractors (MACs).

From Oct. 1 through Dec. 31, short-stay inpatient hospital reviews conducted by the QIOs will be based on Medicare’s current payment policies. Beginning on Jan.1, 2016, QIOs and Recovery Auditors will conduct patient status reviews in accordance with any policy changes finalized in the Outpatient Prospective Payment System (OPPS) rule and effective in calendar year 2016. 

Finally, recovery Auditors may conduct patient status reviews only for those providers that have been referred by the QIO as exhibiting persistent noncompliance with Medicare payment policies, including high denial rates and repeated failure to adhere to the two-midnight rule, or failing to improve performance after QIO educational intervention. 

About the Author

Dawn Crump is the Vice President of Audit Management Solutions at HealthPort. With more than 20 years of experience in the healthcare industry, Dawn exhibits a profound knowledge of hospital revenue cycle practices, audit management, and business intelligence analytics.  Prior to joining HealthPort, Dawn was the Network Director of Audit and Compliance for a Midwest health system. She has healthcare experience in denials management, organizational development, continuous quality improvement (CQI) and corporate compliance.

Comment on this Article

Share This Article