CMS Temporarily Pauses QIO Short Stay and Higher Weighted Diagnosis-Related Group Review

King & Spalding

Effective May 8, 2019, CMS temporarily suspended Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) Short Stay reviews and Higher Weighted Diagnosis-Related Group (HWDRG) reviews. Reviews will be suspended until CMS finds a new BFCC-QIO contractor to perform the Short Stay reviews and the HWDRG reviews. It is anticipated that CMS will award a new contract in the third quarter of 2019. Two contractors – Livanta and Kepro – have been performing the reviews for all 50 states and three territories since 2015, and CMS would like one contractor to perform these reviews on a national basis.

Starting in 2015, BFCC-QIOs began performing Targeted Probe and Educate Short Stay reviews to assess compliance with the Two Midnight Rule. CMS, however, paused BFCC-QIO Short Stay reviews in May 2016 “in an effort to promote consistent application of the medical review policies regarding patient status for short hospital stays and to allow time to improve standardization in the BFCC-QIOs’ review process.” BFCC-QIO Short-Stay reviews resumed in September 2016.

BFCC-QIOs also perform HWDRG-related reviews. When hospitals determine that the original coding sent to the Medicare Administrative Contractor (MAC) for payment was not appropriate, a HWDRG may be requested. The BFCC-QIO reviews these HWDRG assignments post-payment to confirm accuracy.

Kepro’s announcement regarding the temporary review suspension is available here.

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