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CMS Imposes Limit to Look-Back Period for Two-Midnight Reviews

CMS has announced that it has clarified the instructions for medical review of claims affected by the temporary suspension of the BFCC-QIO claim audits under the two-midnight inpatient admissions rule.   Specifically, CMS announced that these reviews will be limited to a six-month look-back period from the date of admission.  Per CMS, 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 our 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.

The imposition of the six-month look-back period is to help ensure that providers receiving denials for Part A claims have sufficient time  to rebill under Medicare Part B.

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