QIOs back to reviewing Two-Midnight rule claims

Beneficiary and Family Centered Care quality improvement organizations (BFCC-QIOs) are back to performing initial patient status reviews to determine whether short stays qualify for Medicare Part A payment under the Two-Midnight Rule as of September 12, 2016. In May 2016, CMS put the reviews on hold “to promote consistent application of the medical review policies” concerning short stays and to standardize the review process. BFCC-QIOs will once again review short stays in acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities.

Pursuant to the Two-Midnight Rule, Medicare Part A will provide coverage for inpatient stays not passing two midnights where, at the time of admission, the admitting practitioner expected the patient to be hospitalized over the span of two midnights or where the practitioner believes that inpatient admission is medically necessary despite an expected stay shorter than two midnights. In both situations, the medical record must support that expectation. During the review hiatus, the BFCC-QIOs underwent retraining on the Two-Midnight Rule and completed re-reviews of claims that had been formally denied. They reached out to providers to discuss claims impacted by the suspension and also to educate them on the Two-Midnight policy. CMS also validated BFCC-QIO peer review activities related to the reviews.

BFFC-QIOs are still expected to follow the CMS guidance entitled, “Reviewing Short Stay Hospital Claims for Patient Status: Admissions On or After January 1, 2016.” CMS will ensure that BFFC-QIOs are complying with requirements by re-reviewing a sample of completed claim reviews on a monthly basis. The agency will also monitoring provider education calls and respond to individual provider inquiries and concerns.