A search for a national review HWDRG contractor is expected in the third quarter.
In a restructuring of the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) jurisdictions, the Centers for Medicare & Medicaid Services (CMS) has created 10 regions across the United States and awarded KEPRO, a BFCC-QIO, a new five-year contract that includes five additional regions. The change is effective June 8, 2019.
KEPRO currently operates in 33 states and the District of Columbia.
Beginning next month, KEPRO will be responsible for Regions 1,4,6,8, and 10. Livanta, the other BFCC-QIO, will be responsible for regions 2, 3, 5, 7, and 9.
Short-stay and Higher-Weighted Diagnosis-Related Group (HWDRG) reviews will no longer be performed by the regional BFCC-QIOs, as CMS will award this contract to a national contractor. CMS anticipates a contract award to be issued by the third quarter of 2019, according to a notice posted on the KEPRO website.
Unclear, however, in the KEPRO announcement is whether the “national contractor” for HWDRG and short stays would be Livanta or KEPRO. Some industry experts believe that both KEPRO and Livanta will vie for the new contract.
As first reported during the May 13 broadcast of Monitor Mondays, Ronald Hirsch, MD told audience members that hospitals had been reporting that the QIOs were doing a poor job with one-day stay reviews for total knee arthroplasty (TKA).
“The QIOs have paused short-stay reviews and higher-weighted DRG reviews to transition from the two incumbent BFCC-QIOs to a single national contractor,” Hirsch said in a statement to RACmonitor. “Recently, as seen on the RAC Relief user group, there have been complaints about the quality of the short-stay reviews, and especially the educational aspect of the targeted probe-and-educate audits. It is unclear if that is a factor in the CMS decision.”
RACmonitor and Monitor Mondays will continue to track this developing story.