Faced with concerns from providers and apparently inconsistent education being provided by the Beneficiary and Family Centered Care Quality Improvement Organizations (QIOs), CMS temporarily suspended reviews of short hospital stays and ordered the QIOs to re-review every denial issued since they took over the reviews.
Beginning Oct. 1, 2015, CMS shifted the enforcement of the Two-Midnight Rule from the Medicare Administrative Contractors (MACs) to two Beneficiary and Family-Centered Care Quality Improvement Organizations (QIOs), Livanta and KEPRO. The QIOs are responsible for conducting reviews of hospital inpatient claims for stays of less than two midnights to determine if they are appropriate for payment under Medicare Part A.
The reviews were suspended in May in order for CMS to re-educate the QIOs to promote consistent application of the medical review of patient status for short hospital stays, according to a CMS announcement. CMS announced in the statement that it expects the suspension to last 60-90 days.
At an Open Door Forum in early June, CMS indicated that it issued the suspension for a number of reasons and gave few details, reports Steven Greenspan, JD, LLM, vice president of regulatory affairs for Executive Health Resources, a Newtown Square, PA, healthcare consulting firm.
“One reason was overall provider concern, but CMS didn’t elaborate. We have heard from smaller hospitals that have been put into the major category when they had only three denials,” Greenspan says.
When CMS announced the audits, it stated that hospitals with a denial rate of more than 20% would be placed in the “major category” and must receive a mandatory educational session with the QIO. If the problem persists, the QIO can refer the hospital to the Recovery Auditor program. CMS released a statement that well over half of the hospitals audited by the QIOs have enough denials to qualify as being of moderate or major concerns.
The problem is, Greenspan says, small hospitals with only a few denials may fall into that category.
Hospitals have also complained that they were denied payment when the case clearly met InterQual criteria, adds Kurt Hopfensperger, MD, JD, senior medical director of audit, compliance, and education at Executive Health Resources.
When the reviews began, CMS stipulated that a nurse from the QIO review the case using InterQual criteria. If it didn’t meet criteria and the nurse couldn’t use his or her clinical judgment to make a decision, the case would be referred to a physician, Hopfensperger says.
CMS representatives also stated during the Open Door Forum that some of its staff sat in on educational sessions provided to hospitals by a QIO and apparently didn’t like what they heard, and that the QIOs were providing inconsistent education, Greenspan says.
“There is a real controversy over what represents a truly valid stay of two midnights,” Hopfensperger says. He points out that the timeframe for the stay does not begin until the order to admit is written. However, if a patient is receiving observation services, even in a bed on the unit, or spends time in the ED, the surgical area, or another treatment area without an inpatient admission order, that period of time does count toward the two-midnight benchmark.
CMS has issued guidelines in the form of a flowchart that shows the way it believes the QIOs should be reviewing cases, Greenspan says. (The guidelines flowchart can be found at: http://bit.ly/29cNuc2.) He suggests that case managers familiarize themselves with CMS guidelines, which show the steps the QIOs should take in approving or denying the case.
According to the guidelines, if a stay of less than two midnights for something that is not on the Inpatient Only List or is not a “rare and unusual” exception (at present only mechanical ventilation), the QIO should establish whether the medical record supports the admitting physician’s determination that the patient required inpatient care despite not meeting the two-midnight benchmark. The guidelines say the admission should be based on complex medical factors such as patient history and comorbidities and current medical needs, severity of signs and symptoms, and risk of an adverse event.
