News Alert: BFCC-QIO Audits Poised to Resume

Original story posted on: April 14, 2021

Providers would do well to prepare by taking a close look at their short stays.

After a multi-year pause due to the COVID-19 pandemic and a contract dispute, it appears that the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) short-stay audits are poised to resume, with Livanta being the sole contactors providing audit services for the whole country, according to an announcement posted to the company’s website on April 12:

As a reminder, these audits will look at inpatient admissions of patients whose inpatient length of stay is less than two days, with audits encompassing both medical and surgical admissions. There is no indication on how Livanta will choose providers for audit, or whether any DRGs will be targeted or exempted. The initial short-stay audits encompassed all providers, but then they transitioned to audits “targeting” providers with a higher percentage of short stays, according to Centers for Medicare & Medicaid Services (CMS) data – and they also included many audits of one-day total knee arthroplasty admissions.

The Program for Evaluating Payment Patterns Electronic Report (PEPPER) measures, which look at short inpatient stays, may give providers a clue if they may be an audit target – although Livanta does not have access to PEPPER, but instead has access to similar data that is only available to CMS contractors. Most hospitals are already reviewing all short inpatient admissions now to determine if the choice of inpatient admission was proper or if the claim should be self-denied and rebilled. It should also be noted that the use of occurrence span code 72 will not preclude an admission from being selected, but those admissions should surpass the two-midnight benchmark, so they should not be at risk of denial unless care was provided as a convenience.

As in the past, Livanta should be reviewing the admissions based on the information available to the physician at the time the admission decision was made, including the reasonable expectation that two midnights of care would be necessary, or that the documentation supports the physician’s determination that the patient with a one-midnight expectation met the case-by-case exception (based on the patient’s comorbidities, severity of signs and symptoms, or the risk of an adverse event). The flow sheet can be found embedded in the article at this link. And as in the past, complete and accurate documentation will be the key to audit success.

There is no indication when additional documentation requests (ADRs) will start being released.

Ronald Hirsch, MD

Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP is vice president of the Regulations and Education Group at R1 Physician Advisory Services. 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. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays.

The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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