CMS Addresses Short Stay Policies in Open Door Forum
Thursday, August 20, 2015 8:09 AM
On August 18, the Centers for Medicare and Medicaid Services (CMS) held an Open Door Forum to discuss hospitals and hospital quality. During the forum, CMS addressed short stay policies.
Officials noted that, in conjunction with proposals in the calendar year (CY) 2016 Outpatient Prospective Payment System (OPPS) Proposed Rule, the Agency has extended its probe and educate review period through December 31.Beginning October 1, quality improvement organizations (QIOs) will take over initial reviews of claims for patient status based on current policies. As of January 1, QIOs and recovery audit contractors (RACs) will carry out reviews based on any policies adopted through the OPPS final rule.
CMS said QIOs will conduct reviews and education sessions in a collaborative manner with providers and will only refer cases to recovery audit contractors (RACs) for further review if there is evidence of a pattern of high levels of short stay claims denials, if a hospital does not respond to educational outreach or if there is some potential of fraud or abuse. The Agency acknowledged that there are questions about parameters for review and how referrals will be made and said more information will be forthcoming.
During the Q-and-A period, providers continued to question the role of QIOs – specifically, whether there will be time limits on reviews, limitations on number of reviews and how a high rate of denials will be defined. CMS stated reviews must occur within 30 days of receipt of medical records by the QIO and that there will be caps on number of reviews based on the size of a hospital – 20 for small providers and 50 for large providers.