Every time I think to myself that I really should try to be nicer to the Centers for Medicare & Medicaid Services (CMS), it does something that sends me right back to my old ways of being critical.
That something for June was the open door forum call that was held on June7. In the call, the agency addressed two major issues. First, they announced that they were delaying the required use of the JW modifier by six months, and then they discussed the pause in the short-stay audits by the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs).
The JW delay was well-received and they were able to answer a few questions, but for the most part they could not provide answers and simply asked questioners to submit their inquiries to the open door forum mailbox.
When it came to the QIO audit delay, they really got me fired up. Several callers explained to CMS that the delay would mean that many of the admissions that were denied and now are going to be re-reviewed have already passed the timely filing limit or come close to it, so if the denial is upheld, the hospital would have no opportunity to rebill.
How did CMS respond to this? They acted as if they had no idea that the QIOs reviewed admissions as far back as May 2015. You know how the QIOs decided which charts to audit? They didn’t decide at all. CMS sent them a list of 10 charts to audit for each hospital. That’s right: CMS told them to audit charts from May 2015, but now they claim they weren’t aware of it.
How is that possible? I am sure someone at CMS reads RACmonitor and has read my description of how CMS changed the eligible claim date on their website in the middle of the night, and the effect that had on timely filing eligibility. Furthermore, there are often CMS representatives listening to my rants on Monitor Mondays – so how could they not know?
On the call, they also claimed that the audits should resume by the end of July, since most of the required re-reviews and education are already done, but I have yet to hear from a hospital that has received either education or results since the pause started – so I suspect the website’s estimate of 60 to 90 days is more realistic. Then, of course, we have no clue of which dates of service they will audit when they resume. Will they go back to 2015 and once again bump up against the timely filing limits, or will they display some common sense and wait to audit until after all education is performed so hospitals are able to use that guidance to improve their processes?
I would like to commend Dr. Larry Field for making a valiant effort to get CMS to give us one example of the new exception for physician judgement. But they recommended that hospitals work with their QIO to develop examples. Sounds great, except does anyone think the Recovery Auditors (RACs) are going to use the same standard as the QIOs? Marc Harstein from CMS even admitted that while the QIOs are tasked with improving quality and work well with hospitals, the RACs are motivated by money; they are under no obligation to use any standard set by the QIOs, especially when following that standard would affect their ability to deny and collect contingency fees.
CMS also introduced their new flowsheet for the QIOs to use when reviewing admissions. I am sure this will be of great help to the QIOs, which did not seem to grasp the concept of a benchmark admission, but step one of the process also seems to suggest that if a patient spends over two midnights as an inpatient, there will be no medical necessity review. Does CMS really not want the QIOs to review these cases for medical necessity of hospitalization for a whole admission? I am hoping that is not the case, and that just like allowing the QIOs to audit admissions from May 2015, this was just an oversight.
While each question asked during the forum had merit, I found one question in particular to be quite sensible, and I hope CMS provides an adequate answer. After hearing multiple questions answered with “please submit that question to the open door forum mailbox,” the caller asked if CMS would consider publishing the answers to these many unanswered questions online instead of waiting until the next open door forum.
But being true to form, CMS was unable to answer even that question.
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 Case Management Association and a Fellow of the American College of Physicians.
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