BREAKING: CMS Stops MAC Recoupment of Short-Stay Denials

By
Original story posted on: January 18, 2019

  • Product Headline: Beyond the CMS Two-Midnight Rule: What You Need to Know About Patient Status and Utilization
  • Product Image: Product Image

Latest move by CMS raises more questions.

CGS, a Medicare Administrative Contractor (MAC), on Thursday released an email notice indicating that the Centers for Medicare & Medicaid Services (CMS) has instructed it to stop seeking recoupment or issuing demand letters for Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) Hospital Short Stay (Two-Midnight Rule) Patient Status Reviews.

In this notice, CGS reported that “CMS has directed (it) to not adjust any claims prior to the implementation date of Change Request 10600, which is Sept. 11, 2018. Therefore, CGS will follow this instruction and will not be seeking recoupment or sending demand letters for any QIO actions.”

The referenced change request and associated MLN Matters, MM10060, outline the required steps for the MACs to process short-stay inpatient admission denials conveyed to them by the BFCC-QIOs, and how formal appeals of these denials should be handled. The MACs are instructed to handle these denials as Non-Medicare Secondary Payer (Non-MSP) provider overpayments; therefore, adjustments to these claims must follow the existing guidelines outlined in the Medicare Financial Management Manual, Chapter 4, Section 10.

“It is unclear from the statement if CMS is instructing the MACs not to recoup any payment for denials issued by the QIOs that has yet to be recouped for denials issued prior to Sept. 11, 2018, or if this prohibition is retroactive to the start of the short-stay audit process by the QIOs, and recoupments already collected will be refunded,” said Ronald Hirsch, MD, in an email to RACmonitor.

RACmonitor will keep investigating this developing story.

Program Note:
Listen to Dr. Hirsch on Monitor Monday, Monday, Jan. 21, at 10 a.m. EST for more details.

 

Comment on this article

Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

This email address is being protected from spambots. You need JavaScript enabled to view it.

Related Articles

  • NEWS ALERT: CMS Posts 2020 IRF Proposed Rule
    Proposed rule calls amending regulations clarifying the determination as to whether a physician qualifies as a rehabilitation physician is made by the IRF. The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule for the inpatient rehabilitation…
  • Medicare Reimbursements Are Property Rights, and Federal Injunctions Can Protect Them
    Could recoupments be unconstitutional? Case law is changing in favor of healthcare providers who accept Medicare and/or Medicaid. Without question, accepting Medicare and/or Medicaid payments creates a legal risk of regulatory audits. Because the reimbursements constitute tax dollars, the federal…
  • CMS Mulls Regulating Shared Space in Provider-based Settings
    Guidance expected to address when a provider-based location shares space with a clinic or another hospital. At the American Health Lawyers Association Medicare and Medicaid conference in March, David Wright, acting deputy director for the Center for Clinical Standards and…