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.

CMS creates new Hospital Improvement and Innovation Networks to improve safety and reduce readmissions

CMS is planning to further strengthen patient safety, improve hospital care quality and reduce readmissions by creating a series of Hospital Improvement and Innovation Networks (HIINs), according to a blog post by CMS Chief Medical Officer Patrick Conway, M.D. The HIINs will continue the work of the Hospital Engagement Networks (HENs), which are part of the Partnership for Patients under the umbrella of the Quality Improvement Organization (QIO) program.


According to Conway, HIINs will “tap into the deep experience, capabilities and impact of QIOs, hospital associations, hospital systems, and national hospital affinity organizations with extensive experience in hospital quality improvement.” The networks will work to engage and support hospitals, patients, and their caregivers to implement and spread best practices to hospitals at a national scale. The goal of HIINs is that through 2019, new HIINs will work to achieve a 20 percent decrease in overall patient harm and a 12 percent reduction in 30-day hospital readmissions as a population-based measure (readmissions per 1,000 people) from the 2014 baseline.

Section 3025 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) included provisions to help hospitals reduce readmissions and keep patients safe. To date, there has been success in reaching this goal. Conway emphasized the findings of a recent Agency for Healthcare Research and Quality (AHRQ) report, which found “an unprecedented 39 percent reduction in preventable patient harm in U.S. hospitals compared to the 2010 baseline,” and that CMS’ current efforts have “resulted in 2.1 million fewer patients harmed, 87,000 lives saved, and nearly $20 billion in cost-savings from 2010 to 2014” (see Thousands of lives, billions of dollars saved by Affordable Care Act, December 2, 2015). Conway also pointed out substantial progress has also been made in reducing 30-day hospital readmissions. In light of so much success, CMS is looking to further its reach.

Request for Proposals

CMS issued a request for proposals (RFP) for HIINs, which is open to all organizations, including those who operated under the HEN banner in Partnership for Patients’ first and second rounds. Conway noted that CMS is encouraging all interested parties to submit a proposal for a “full and open competition” that “will continue to build on the successes achieved so far.”