Reviews of Short Stay Hospital Claims Have Resumed as of Sept. 12, 2016

The Centers for Medicare and Medicaid Services (CMS) recently announced the resumption of initial patient status reviews to determine the appropriateness of Medicare Part A payment for short hospital stays, effective Sept. 12, 2016.

As of May 4, 2016, CMS had temporarily paused the Beneficiary and Family Centered Care Quality Improvement Organizations' (BFCC-QIOs) reviews, because CMS became aware of inconsistencies in the BFCC-QIO's application of the two-midnight policy for short hospital stay reviews.

CMS says it lifted the temporary suspension of short stay reviews since the following steps to strengthen the consistency of the review process have been taken:

  • BFCC-QIOs successfully completed re-training on the two-midnight rule, which stipulates that, for hospital stays that span less than two midnights to be payable under Medicare Part A, admitting physician documentation in the patient's medical record must support the necessity of inpatient admission.
  • BFCC-QIOs have completed a re-review of claims that were previously denied.
  • CMS examined and validated BFCC-QIO peer-review activities connected to short-stay reviews.
  • BFCC-QIOs performed provider outreach on claims impacted by the temporary suspension and initiated outreach and education on the two-midnight policy.

What's the Bottom Line for Physicians?

Hospital stays that do not meet the two-midnight rule for inpatient admission could still be considered for Part A payment on a case-by-case basis. Appropriate documentation by the admitting physician which clarifies the medical necessary of the admission is crucial.

CMS will also continue to oversee BFCC-QIO reviews of short stay hospital claims by taking these steps:

  • Re-reviewing a sample of BFCC-QIO completed claim reviews each month
  • Monitoring provider education calls
  • Responding to individual provider inquiries and concerns. Physicians and other health care providers can email questions via the CMS Open Door Forum Mailbox at ODF@cms.hhs.gov.

More Resources

CMS offers the following resources that can help clarify the two-midnight rule and the recent temporary pause in reviews:

Pennsylvania Medical Society (PAMED) members with questions can also call PAMED's Knowledge Center at 855-PAMED4U (855-726-3348).

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