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BFCC-QIOs to Resume Two-Midnight Reviews

CMS has announced that, effective September 12, 2016, BFCC-QIOs will resume initial patient status reviews of short stays in acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities to determine the appropriateness of Part A payment for short stay hospital claims.  Per the CMS announcement, the temporary suspension, which was instituted on May 4, 2016, is being lifted because:

• The BFCC-QIOs successfully completed re-training on the Two-Midnight policy;
• The BFCC-QIOs have completed a re-review of claims that were previously formally denied;
• CMS examined and validated the BFCC-QIOs peer review activities related to short stay reviews;
• The BFCC-QIOs performed provider outreach on claims impacted by the temporary suspension; and
• The BFCC-QIOs initiated provider outreach and education regarding the Two-Midnight policy

CMS has not made any changes to the guidance under which the BFCC-QIOs will perform their reviews.  The BFCC-QIOs will continue to follow the guidance entitled, “Reviewing Short Stay Hospital Claims for Patient Status: Admissions On or After January 1, 2016.”  The outreach and education requirements detailed in the CY 2016 OPPS Final Rule also remain in effect.

Beginning June 6, 2016, CMS instructed the BFCC-QIOs to re-review all short stay patient status claims that were denied under the QIO medical review process. To address hospitals’ concerns that they do not have the opportunity to rebill for medically necessary Medicare Part B services by the time a medical review contractor has denied a Medicare Part A claim, CMS announced that these reviews would be limited to a six-month look-back period from the date of admission and that Medicare Fee-For-Service (FFS) claims that:

1. Are outside the six-month look-back period and were formally denied (as defined below) are being removed from the provider sample for re-review and will be paid under Part A.
2. Are outside the six-month look-back period and were not formally denied are being removed from the provider sample for re-review and will be paid under Part A.
3. Are within the six-month look-back period and were not formally denied will be reviewed when we resume QIO reviews as per issued sub-regulatory guidance.
4. Are within the six-month look-back period and were formally denied are being re-reviewed by the BFCC-QIO to determine whether the initial review decision was consistent with the two-midnight policy in effect at the time of the hospital admission.

If a hospital had already submitted an appeal for a denied claim, the BFCC-QIO was directed to share its re-review findings with the appeals adjudicators to be taken into consideration during the appeal process. If upon re-review it is determined that the claim was incorrectly denied, the appeals adjudicators would issue revised determinations as necessary.

Given the resumption of BFCC-QIO short-stay reviews, providers should be prepared for BFCC-QIO review of claims that fall within the six-month look back period and were not formally denied.  For other claims we would advise providers to (1) ensure that denied claims that fall within the six-month look back period were appropriately reviewed by the BFCC-QIO and (2) that any denied claims that fall outside the six-month look back period have been paid (these claims were removed from the QIO audit sample and should have been paid under Part A).

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