In order to secure a new Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) contractor, the Centers for Medicare and Medicaid Services (CMS) has temporarily paused both Short Stay and Higher Weighted Diagnosis-Related Group (HWDRG) reviews.
Previously, two BFCC-QIOs have performed HWDRG reviews since 2014 and Short Stay reviews since 2015 for all 50 states and three territories: Kepro and Livanta. Moving forward, one organization will handle both types of reviews on a national basis.
Short Stay reviews provide an opportunity for BFCC-QIOs to ensure doctors and hospitals are maintaining compliance with the Medicare Part A payment policy for inpatient admission. BFCC-QIOs assumed responsibility of conducting Short Stay reviews on October 1, 2015. Previously, the reviews were conducted by Medicare Administrative Contractors (MACs) and Recovery Auditors.
An HWDRG review may be requested when a facility has determined that the originally assigned DRG did not appropriately reflect the services provided to the patient. After the MAC processes the request, CMS may select it for BFCC-QIO post-payment review.
A similar temporary pause of Short Stay reviews occurred in May of 2016. This pause allowed CMS to promote consistent application of the medical review of patient status for short hospital stays after becoming aware of inconsistencies in the BFCC-QIOs’ application of the two-midnight policy. The BFCC-QIOs were then required to re-review all denied claims in the previous seven months in order to ensure accuracy. The May 2016 pause ended September 12, 2016.
CMS expects an end to the pause of reviews by the third quarter of 2019, when a contract award will be issued. The Health Law Partners will continue to monitor and report updates as they become available. For more information regarding Short Stay and HWDRG reviews, please contact Jessica L. Gustafson, Esq. and Abby Pendleton, Esq.