May 25, 2016

Beyond Words: The QIO Short-Stay Suspension

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As I reported in last week’s RACmonitor eNews, the Centers for Medicare & Medicaid Services (CMS) has told the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) to halt their audits of short inpatient admissions.

And I have to say that this whole fiasco is really beyond words. CMS introduced the two-midnight rule over three years ago, and the contractors that are paid a heck of a lot of money to familiarize themselves with CMS regulations can’t seem to get it right.

First, CMS asked the Medicare Administrative Contractors (MACs) to conduct probe-and-educate audits, and that was a disaster. We all went through two or three rounds of education, but in reality, most of the hospitals learned the rule from places such as RACmonitor, online forums such as RAC Relief, and during conferences with speakers such as Day Egusquiza, who we heard from last week on Monitor Mondays (when thousands also watched my YouTube video, through which I teach the two-midnight rule in a six-minute cartoon).

So, what did CMS do as we got better? It transitioned reviews from the MACs to the BFCC-QIOs. And once again, that did not go well. I am still fuming that CMS changed the claims-eligible-for-audit date of admission from Oct. 1, 2015 to May 1, 2015 by sneakily changing a document on a holiday evening, as if no one would ever notice (see the mysteriously changing tables here.) Then the agency told the QIOs to start the second round of audits knowing full well that the majority of hospitals had not received their first round of education. CMS also did not train the QIOs properly, because early this month it instructed the QIOs to halt all their audits until retraining could take place. 

It appeared that the biggest problem the QIOs had was with benchmark admissions: patients who spent one midnight as outpatient and one as inpatient. What does that entail? Look at the chart, determine when care began, start counting the number of midnights the patient was in the hospital from that point (but stop counting when you get to two), and then determine if the patient exhibited medical necessity for hospital care for both midnights. That’s all it takes.

There is some clinical judgment to be made as to whether a patient required hospital care, and definitely judgment if the patient only spent one midnight, but the QIOs have plenty of practicing doctors that can help with that determination. They just need proper training. And I once again offer my services, free of charge, to CMS to give lectures to whomever they want to be taught the rule properly. And of course, my YouTube videos are available to anyone, anywhere, with an internet connection.

We don’t know when the audits will resume, or what will change, or how they will address the timely filing deadline that has now passed on many of the first-round cases, but once again it is hospitals that are caught in the middle. And with the new adjustable record limits for Recovery Auditors (RAs), a lot more is at stake for hospitals. And except for one report of an inpatient admission approved for a patient who had complete heart block and got a pacemaker and went home the next day, we have no idea how to apply the new exception for physician judgment of the necessity of inpatient admission, despite an expectation of less than two midnights.

Well, if nothing else, this mess will continue to give me topics for Monitor Mondays and the RACmonitor eNews for a long time to come.

About the Author:

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians.

Contact the Author

RHirsch@accretivehealth.com

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