November 7, 2013

CMS Delays Post-Payment Claim Reviews Again

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Reporting that additional clarifications are to be expected soon, the Centers for Medicare & Medicaid Services (CMS) this week announced that it would not conduct post-payment patient status reviews for claims with dates of admission of Oct. 1, 2013 through March 31, 2014 — a period three months longer than that of the agency’s previous delay.

In a posting on its website, CMS indicated that it would “conduct prepayment patient status probe reviews for dates of admission on or after October 1, 2013 but before March 31, 2014.” The agency also noted that Medicare Administrative Contractors (MACs) would conduct patient status reviews using what it described as a “probe-and-educate strategy” for claims submitted by acute-care inpatient hospital facilities, long-term care hospitals (LTCHs), critical access hospitals (CAHs), as well as inpatient psychiatric facilities (IPFs) for dates of admission falling within that time frame.

“My reaction is some relief in that we have an extra 90 days to get our act together,” Mike Jamrog, compliance and privacy officer for McLaren Bay Region, told RACmonitor in an email. “It bothers me a little that CMS was so shortsighted before to think the MACs could sample, review, and communicate the results of their review with all the providers in order to educate on the providers adherence to the two-midnight rule.”

Jamrog described the development as a “major change in patient assessment and provider operations.”

“Trying to rush ahead only gets you in trouble,” Jamrog said. “Providers need to take advantage of the time. If they waste it, then (there is) nobody to blame for problems except themselves.”

In explaining how the MACs will employ the “probe-and-educate” strategy, CMS indicated that the contractors would select a sample of 10 claims for prepayment review for “most hospitals” but 25 sample claims for larger ones.

“Based on the results of these initial reviews, MACs will conduct educational outreach efforts and repeat the process where necessary,” CMS said in its guidance.

On the other hand, again, CMS indicated that it would not perform post-payment patient status reviews for claims with the aforementioned dates of admission.

With respect to Recovery Audit Contractors (RACs), CMS noted that RACs would “limit prepayment reviews to therapy services, per statutory mandate, until further notice” – although the agency noted that RACs could complete reviews for previously requested documentation for claims with dates of service prior to Oct. 1, 2013.

CMS was quick to point out that MACs, RACs and Supplemental Medical Review Contractors would continue other types of inpatient hospital reviews, including coding reviews and reviews of medical necessity of surgical procedures provided to hospitalized beneficiaries.

In addition, inpatient hospital patient status reviews would continue for dates of admission prior to Oct.1, 2013, “based on the applicable policy at the time of admission,” noted CMS.

CMS further noted that post-payment inpatient hospital patient status and medical necessity reviews are “limited to claims for 1) short stays defined as inpatient zero or one utilization day (less than two midnight) stays, 2) for claims with dates of admission prior to Oct. 1, 2013, and 3) for previously approved complex issues.”

Finally, reminding readers that an updated Q&A document would be released soon, CMS noted that automated and semi-automated reviews that are “approved, or approved complex reviews for issues other than medical necessity of the inpatient admission (i.e. DRG validation), will continue unless otherwise specified by direction from CMS.”

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Chuck Buck is the publisher of RACmonitor.

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Chuck Buck

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

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