August 1, 2016

CMS Changes Rules Governing QIO Audits Again

By

Today is a day to proclaim another victory for Monitor Mondays and RACmonitor.

As you may recall, I have discussed in several previous articles the shenanigans played by the Centers for Medicare & Medicaid Services (CMS) as it pertains to the resumption of short-stay audits. First, in the middle of the night on New Year’s Eve, the agency changed the date for the admissions that were eligible for audit, moving it back almost six months. Then they put a pause on the audits due to poor performance by the quality improvement organizations (QIOs) without regard to the timely filing deadlines faced by hospitals. 

Without the fanfare that it deserved, on Thursday CMS released an update to its audit policy and made up for all their previous indiscretions by formally imposing a six-month lookback period on these audits. Furthermore, CMS has told the QIOs to approve for payment all of the admissions that it already reviewed but was holding for re-review that are more than six months old. That includes any admission CMS denied on initial review and those that it had not yet even reviewed. That’s right; even if an admission was denied, you are going to get paid and it won’t be considered a denial.

Again, CMS announced that short-stay inpatient admission reviews will be limited to a six-month lookback period from the date of admission. The agency also announced that claims that:

  1. Are outside the six-month lookback period and were formally denied are being removed from the provider sample for re-review and will be paid under Part A.
  2. Are outside the six-month lookback 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 lookback period and were not formally denied will be reviewed when the QIOs resume reviews.
  4. Are within the six-month lookback period and were formally denied are being re-reviewed by the QIOs to determine whether the initial review decision was consistent with the two-midnight policy in effect at the time of the hospital admission.

Now, I would like to proclaim that we won both the battle and the war, but we still have two issues that need close ongoing scrutiny. First is the accuracy of the QIO audits. As I previously described, many of the QIO auditors had great difficulty understanding the two-midnight benchmark. So we need to see that they finally got that figured out.

Second is the issue of timeliness of the QIO reviews. When the audits started, the QIOs simply had to audit 10 charts from each hospital. That’s 10, not 100 or 500. And they had 30 days to do it: a whole month. But they could not.

Sure, in that case it worked out, since CMS stopped the audits, but what is gong to happen when they resume? With the six-month lookback period, 30 days to review the admission (if they can hit that deadline), then factor in the time needed to schedule a discussion call with the hospital, produce a final determination, forward that to the Medicare Administrative Contractor for processing, and finally issuance of the formal denial, some appeals could once again butt right up against timely filing deadlines, limiting the ability of hospitals to get paid under Part B.

I want to be optimistic that it will all work out, and I am grateful that CMS saw the light, but it’s just in my nature to maintain a healthy skepticism. And if and when the process breaks again, I’ll be here to report on it.

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 

Comment on this Article

editor@racmonitor.com

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