On May 4, 2016, the Centers for Medicare & Medicaid (CMS) announced that the Quality Improvement Organizations (QIOs) were to suspend further claim audits regarding short stays. This suspension or pause is expected to be between 60-90 days. Last October 1, 2015, The QIOs had been given the CMS contract from the Medicare Administrative Contractors (MACs) to review these billed claims.
The purpose for this pause is for CMS to standardize the QIO review process, provide training to the QIOs regarding the 2 midnight (2MN) rule, evaluate previous QIO denied claims as well as conduct provider education. Therefore, the intent is for CMS to promote a consistent application of patient status medical reviews on short hospital stays.
The suspension of reviews was a result of many hospital complaints that the QIOs were not following regulatory requirements surrounding the 2MN stay. In particularly, the QIOs were not counting the time patients were in observation, nor the Emergency Department as part of the stay which would qualify for inpatient status if the span of time covered 2 midnights.
According to the American Hospital Association, hospitals were also concerned that the time between QIO audits did not allow hospitals to provide education and/or make Improvements prior to the next audit. In addition, the QIOs delayed receipt of review results which prompted hospitals to rebill denied claims under Part B due to the one year filing timeline. Had the reviews been more timely, it may have prevented hospitals from rebilling.