Unique opportunity. Hospitals urged to use great discretion.

The Centers for Medicare & Medicaid Services (CMS) wants to know if your total knee replacement (TKR) claims have been denied.

Ronald Hirsch, MD, made the announcement today during the weekly broadcast of Monitor Mondays when he reported that he has received messages from a number of provider organizations about what he described as the continuing TKR “saga.”

Notable among those wanting more information on the denied claims was Steven C. Rubio, CMS director of the agency’s Beneficiary Health Improvement & Safety subsection of the Quality Improvement & Innovation Group.

Hirsch said he received responses to his RACmonitor news report last Thursday about one-day stay inpatient TKRs being denied by the Quality Improvement Organizations (QIOs) despite documentation of high risk.

“The Livanta BFCC-QIO physician stated that they would only approve TKRs for patients who either had an expectation of two midnights or actually spent two midnights in the facility – which, as a reminder, totally contradicts the regulations that permit inpatient admission for one-midnight stays on a case-by-case basis,” Hirsch told the Monitor Mondays audience.

Hirsch said he received an email from the aforementioned Rubio, and that from the tone of it, Hirsch opined that CMS wasn’t pleased that the QIOs seem to be ignoring CMS regulations.

“Mr. Rubio has asked me to put out a request for hospitals that have had similar denials to contact him with the case details so that his staff can review the medical records and the denials,” Hirsch said. “To be clear, the hospital should still discuss the case with the QIO as part of the probe-and-educate process (Targeted Probe and Educate) and proceed with a formal appeal, if warranted; this review by CMS will not result in an overturn of a denial in and of itself.”

Hirsch told the audience that the offer from CMS was “a unique opportunity” and advised to use it with “great discretion.”

“Evaluate your denial and see if the patient was truly high-risk, and that the high-risk factors were clearly documented pre-operatively,” Hirsch explained. “If so, send the claim number (not the patient’s Medicare ID number), a summary of the case, and details of any discussions you have had with the QIO to Steven.Rubio@cms.hhs.gov with the subject line: QIO Denial of Total Knee Replacement.”

Hirsch reminded listeners to be sure there that is no protected health information in the email. Hirsch also cautioned that submitters would most likely not hear back from Mr. Rubio.

“Your submission will contribute to ensuring that the QIOs are evaluating admissions properly and ensuring that all hospitals can follow the regulations as CMS intended them, without fear of an inappropriate denial,” Hirsch concluded.

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