Quality Improvement Organization Changes and Upcoming Events

by Kimberly Anderwood Hoy Baker, JD

Last week, CMS published information on a “temporary pause” to the 2-Midnight reviews by the QIOs. Before I cover some details on the pause, I also wanted to share some upcoming events where HCPro regulatory specialists will be speaking.

I’m excited to be at the national Optum Forum as a guest speaker for Executive Health Resources’ (EHR) track in August. I will be speaking on the financial implications of inpatient and outpatient status. I hear lots of confusion about patient responsibility, and I plan to review hospital payments and patient responsibility for similar services under the inpatient and outpatient payment systems. The closing keynote speaker is Michael J. Fox, and I’m excited to get to attend that session. For more information, visit www.optumforum.com.

In September, HCPro is hosting an expanded version of our Medicare Compliance Forum. To better describe the new scope, the forum will now be known as the Revenue Integrity Symposium. There will be sessions on the Medicare overpayment reporting rule. inpatient-only procedures, the IPPS rule for 2017, CDI in critical access hospitals, changes for rural health clinics, chargemaster, infusions and injections, and a general session on Revenue Integrity Basics. I’ll be presenting on the new observation notice and all the changes for provider-based billing, as well as teaming up with Ralph Wuebker, MD, MBA, and Steven Greenspan, JD, LLM, from EHR on the 2-Midnight Rule and condition code 44 and W2 processes. Experts from HCPro's coding and CDI teams will also be presenting on those topics. For more information, visit http://hcmarketplace.com/revenue-integrity-symposium .

Now for CMS’ pause of patient status reviews. CMS posted information on their Inpatient Hospital Reviews website last week regarding a “temporary pause” of 60–90 days in the short-stay patient status reviews by the QIOs KEPRO and Livanta. The pause, which began May 4, was to address inconsistencies in application of the 2-Midnight Rule by the QIOs in their medical review of inpatient hospital claims, according to CMS. During the pause, the QIOs will complete retraining on the practical application of the 2-Midnight Rule, re-review previously denied claims, and perform provider outreach and education to providers on re-reviewed claims. However, CMS did not announce an extension of time frames to appeal. Therefore, providers with appeal rights that could expire may need to appeal to preserve their appeal rights in the event that a re-reviewed claim continues to be denied. CMS has also instructed the QIOs to work with appeal contractors for appealed cases that are re-reviewed and approved to ensure the appeal contractor can issue redeterminations in the provider’s favor, if necessary.

In addition to information on the temporary pause, CMS also published a review algorithm for conducting 2-Midnight reviews. This algorithm may be helpful to UR committees in their post-discharge reviews and when providing education in their facilities.

To view the complete article that appeared on Medicare Compliance Watch, click here.