KEPRO, one of the Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIOs), presented webinars introducing the resumption of the audits of short-stay inpatient admissions, also known as two-midnight audits.

There was a great deal of anticipation for these webinars in light of the poor performance by the QIOs on the first attempt at auditing these admissions. The webinars were conducted last week.

As had been discussed on RACmonitor, there was a general misunderstanding about how to count midnights to reach the two-midnight benchmark with the QIO reviewers, which have been denying inpatient admissions for patients who spent the first midnight as outpatients and then were admitted as inpatients for the second, medically necessary midnights (contrary to Centers for Medicare & Medicaid Services (CMS) guidance).

CMS paused the audits from May 4 to Sept. 12 to “allow reeducation.”

This webinar was intended to once again educate the provider community on how the QIOs will conduct their audits.

So, how did KEPRO do?

Not very well. Or, to use their terminology, this reviewer has “major concerns” with the presentation. From the beginning it was clear that it was going to be a less-than-optimal experience. The presenter spent almost 30 minutes reviewing the history of the QIO program, the role of KEPRO, and the reason for the two-midnight rule, then went into painfully extreme detail reviewing the credentials of the QIO leaders. (Was it helpful for us to know that their medical director was previously medical director at another QIO?)  

They even described the audit pause, indicating that it was done “to ensure consistency between contractors.” At this point, an apology for their poor work product would have gone a long way, with many of the viewers who had spent the last few months of 2015 and first five months of 2016 responding to medical record requests and fighting inappropriate denials.

Alas, no apology was offered.

When I posted a comment suggesting that an apology was in order, it was met with a response to “please keep the chat box for legitimate questions that pertain to the presentation or specifics to the review process.” To anger providers even more, they stated that all previous cases were closed, allowing CMS to start the new audits. Yet several comments were immediately posted from providers that had still not received results letters informing them about the status of their claims.

Once the presenter got into the review process that the QIOs would use, the presentation got no better (and probably drove the webinar rating down from “minor concern” to “major concern.”) The two-midnight rule was reviewed, starting with the need for an inpatient order, but throughout this portion, the presenter continually referred to “physician certification of the inpatient admission,” citing a reference to a January 2014 CMS document. As most listeners knew, but apparently unknown to the presenter and KEPRO, CMS rescinded the need for physician certification of all inpatient admissions in the 2015 Outpatient Prospective Payment System rule. 

The confusion was also compounded when they presented a slide indicating that the “two-midnight benchmark is based upon the physician’s expectation of the required duration of medically necessary hospital services at the time the inpatient order is written and formal admission begins.” Is it possible for any statement to be more ambiguous than this? Does this mean that they will be looking for an expectation of two midnights, starting at the time the inpatient order is written, as this language literally states, or will they be counting all medically necessary midnights that have already occurred, as the two-midnight rule requires? They also indicated on a slide that “excluded claims involve indirect medical education (IME).” It is unclear how that would work; every inpatient claim from a teaching hospital includes an IME payment. Does that mean that no claims from teaching hospitals will be audited? Or that a denial will result in recoupment of the payment, less the IME amount?

In the first presentation, held Sept. 19, the presenter indicated that the “clinical improvement” exception only applies to patients who undergo a procedure and are able to go home after one midnight. But the presenter did not indicate that this is applicable to medical patients. That makes no sense at all; the two-midnight expectation does not apply to inpatient-only surgery, and non-inpatient only surgery should be performed as outpatient (rarely should those patients be admitted as inpatients). She did not make the same comment the next day, perhaps due to my posted comment. So which is it, or rather, which do they think it is, since we all know that it applies to all patients?

Interestingly, it was stated that they will be excluding admissions with a discharge status of 02 (transferred to another acute-care hospital), 20 (expired), and 07 (left against medical advice, or AMA.) While the AMA and expired patient exclusions make sense, not all transfer patients meet the two-midnight expectation. For example, consider a patient for whom plans are made for immediate transfer, but instead he or she is placed upstairs awaiting an open bed at the accepting hospital. Such a patient should initially be placed as an outpatient with observation services, and only admitted if they stay past the second midnight. But this exclusion suggests (but does not state explicitly) that such patients could be admitted as inpatients from the time of the admission decision.

The presenter was also very non-explicit when discussing delays in care. One slide noted that “BFCC-QIOs will continue to follow CMS guidance that payment is prohibited for extensive delays in providing medically necessary care.” What is “extensive?” CMS refers to delays in care and the word “extensive” is extremely subjective.

The case example was a patient who presented on a Friday, needing a cardiac cauterization that could not be done until Monday. I don’t think there is any argument that one would not include those two midnights for such a delay, but what about a patient who presents on Saturday and needs a stress test on Sunday that cannot be done until Monday; is that one-midnight delay considered an “extensive” delay that should not be counted, or an “acceptable” delay and that midnight can be counted? Or what about a consultant who rounded in the morning and does not want to return to see an afternoon consult; can we count that as an “acceptable” delay and count that midnight?

The issue of the new exception for “physician judgment for the need for inpatient admission despite an expectation of less than two midnights” was totally glossed over, with absolutely no case examples provided. Yet on a recent open door forum call, when asked about case examples by Dr. Larry Field, CMS instructed the provider community to get such case examples from the QIOs.  

How are we to use an exception in the “rare and unusual exception policy” (which CMS clarified does not mean that they think that one-day inpatient admissions are either rare or unusual) without some idea of what cases fit that exception?

Because of the number of listeners (1,000 on Sept. 19 and 500 the next day), they did not take direct questions but asked listeners to type their questions in the chat box, with responses to be collated and posted to their website in the future.

Of course, with record requests reportedly going out starting this week, “the future” is too long to wait for answers to simple questions, such as how the QIOs will handle occurrence span code 72, or what to do if an inpatient-only surgery chart is requested.

I have a log of the 22 pages of questions that were posted and will keep you up to date on the responses, if there are any.

And now we wait for the chart requests to start…

About the Author

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians.

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