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Quality Improvement Organizations (QIOs) 10/1/15 through 12/31/2015 Assume responsibility for conducting initial patient status reviews of providers to determine the appropriateness of Part A payment for short stay inpatient hospital claims. Reviews previously conducted by the Medicare Administrative Contractors (MACs). Based on Medicare’s current payment policies. Beginning on January 1, 2016, QIOs and Recovery Auditors will conduct patient status reviews in accordance with any policy changes finalized in the OPPS rule and effective in calendar year
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Home Town HealthDenial Update
October 14, 2015
Agenda• Inpatient Hospital Reviews– Quality Improvement Organizations (QIOs)– Medicare Administrative Contractors (MACs)– Recovery Auditors
• MedPerformance iMAD
• Reference material https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review/inpatienthospitalreviews.html
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Quality Improvement Organizations (QIOs)
• 10/1/15 through 12/31/2015• Assume responsibility for conducting initial patient status
reviews of providers to determine the appropriateness of Part A payment for short stay inpatient hospital claims.
• Reviews previously conducted by the Medicare Administrative Contractors (MACs).
• Based on Medicare’s current payment policies. • Beginning on January 1, 2016, QIOs and Recovery Auditors
will conduct patient status reviews in accordance with any policy changes finalized in the OPPS rule and effective in calendar year 2016.
3Q I O
Medicare Administrative Contractors (MACs)• Currently conducting the third round of Inpatient Probe and
Educate reviews • After October 1, 2015, MACs may continue to conduct CMS-
approved claim reviews unrelated to patient status (e.g., coding reviews, reviews to determine the medical necessity of the procedure conducted, etc.).
• May also continue with education
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Recovery Auditors• Moratorium on Recovery Auditor patient status reviews will
expire on October 1, 2015 (Section 521 of the Medicare Access and CHIP Reauthorization Act of 2015, (Pub. L. 114-10)).
• CMS will not approve Recovery Auditors to conduct patient status reviews for dates of admission of October 1, 2015 through December 31, 2015.
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Recovery Auditors• Reviews begin again January 2016• Only patient status reviews for those providers that have been
referred by the QIO as exhibiting persistent noncompliance with the following Medicare payment policies:– having high denial rates and – consistently failing to adhere to the Two Midnight rule (including
repeatedly submitting inappropriate inpatient claims for stays that do not span one midnight), or
– failing to improve their performance after QIO educational intervention.
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Recovery Auditors• Recovery Auditors may continue to conduct reviews of short
stay inpatient claims for other reasons, including CMS-approved claim reviews unrelated to patient status (e.g., coding reviews, reviews to determine the medical necessity of the procedure conducted, etc.).
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Recovery Auditors• Note: These changes in enforcement and education strategies
will not affect the reviews conducted by the Comprehensive Error Rate Testing (CERT) contractor or those reviews conducted for the purpose of identifying fraudulent behaviors, such as Zone Program Integrity Contractor reviews.
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Summary of Inpatient Status Reviews
Date of Admission Contractor Type(s)
Through September 30, 2015 MACs conducting probe and educate.
October 1, 2015 through December 31, 2015
QIOs conducting reviews. MACs completing some remaining provider education.
January 1, 2016 and beyond QIOs conducting initial reviews. RACs conducting further reviews upon referral by QIOs.
Recent PROBE Results• 50% error rate by numbers• 42% error rate by reimbursement• Lack of documentation of expectation of a 2MN stay• Orders not authenticated by physician prior to discharge• Surgeries not on the Inpatient Only List
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MedPerformance iMAD• MedPerformance has a powerful and easy to use Denial
Management System “iMAD” that can help you reduce your denials
• MedPerformance can help you with manage your denials with experienced staff
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iMAD Contact InformationFor more information, please contact:
MedPerformance LLCRebecca Corzine Tarr
Owner(813) 786-8974
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