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CMS Announcement: Short Stay Review Resume

by | Sep 29, 2016 | Clinical Performance | 0 comments

5 Clinical Performance 5 CMS Announcement: Short Stay Review Resume

After a brief pause for the Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIOs), BFCC-QIOs will resume patient status reviews of short stays in acute care inpatient hospitals.

Effective September 12, 2016, BFCC-QIOs will be performing initial patient status reviews to determine the appropriateness of Part A payment for short stay hospital claims. The suspension of the short stay reviews allowed BFCC-QIOs to complete their own re-training on the Two-Midnight policy along with the initiation of provider outreach and education. This pause also allowed BFCC time to complete a re-review of claims that were previously formally denied, allowing CMS to confidently confirm the peer review process and activities related to short stay reviews.

The guidance that the BFCC-QIOs is using to conduct the short stay reviews has not changed, the details can be found on the CMS site HERE:

A summary of the BFCC-QIOs guidelines include:

  • Recovery Auditors will only be brought in after a referral from the QIOs indicate that a provider is exhibiting persistent noncompliance with Medicare payment policies
  • Patient status review will exam the medical record to assess the hospital’s compliance with:
    • the admission order requirements
    • the 2-midnight benchmark
  • A minimum of 10 records in a 30-45-day time period from hospitals and the maximum number of record requests per 30 days will be 30 records
  • Exempt from review will be all inpatient records where services on Medicare’s Inpatient Only List were performed regardless of the expected length of stay
  • Reviewing admission orders based upon the medical record documentation exhibiting medically necessary hospital services for 2 or more midnights for inpatient payment under Medicare Part A.
  • “Start clock” of the 2 midnight time mark will be reviewed to ensure the services and care was received by the beneficiary during the 2 midnight benchmark
  • Extensive delays in medically necessary services will be taken into consideration in the 2 midnight benchmark calculation

BFCC-QIOs are not the only auditing entity, CMS will bring in the Comprehensive Error Rate Testing (CERT) contractor, First-look Analysis for Hospital Outlier Monitoring (FATHOM) and Program for Evaluating Payment Patterns Electronic Report (PEPPER) to identify and monitor inpatient hospital claims. So now is a good time to do your own audit and review of short stay cases, contact Clinical Intelligence and we can show you how easy it can be done with ClinView. Call 1-888.341.1014 or email [email protected].

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