If it “Sounds Too Good To Be True”, It Probably Is

on Friday, 22 November 2013. All News Items | Case Management | Medicare Coverage

Alert: CMS has issued a One-Time Notification (Transmittal 1315) regarding the Immediate Suspension of Postpayment Patient Status Reviews of Inpatient Hospital Admissions 10/1/13 – 12/31/13. At first glance hospitals may breathe a sigh of relief at the “reprieve” from Medicare Administrative Contractor (MAC), Recovery Auditors (RAs) and Supplemental Medical Review Contractors (SMRs) reviews. However with almost all things that “Sound too good to be true” so is that sigh of relief.

Transmittal Summary of Changes:

CMS indicates that “reviews to check compliance with Final Rule CMS-1599-F are called “patient status” reviews. The purpose of this Change Request is to provide the contractors with instruction regarding their post-payment medical review strategy, particularly related to “patient status” reviews.

Specifically, the Transmittal instructs that MACs, RAs and SMRs “shall not conduct postpayment patient status reviews for inpatient claims with the dates of admission 10/1/13 – 12/31/13. However, claims with evidence of systematic gaming, abuse or delays in the provision of care in an attempt to surpass the 2 midnight presumption could warrant medical review at any time.”

The Transmittal goes on to provide the instruction that these Contractors can continue other types of inpatient hospital reviews.

What does this really mean for Hospitals?

  • Contractors cannot conduct postpayment “patient status” reviews for inpatient claims with dates of admission 10/1/13 – 12/31/13.
  • Contractors can audit claims with “evidence of systematic gaming, abuse of delays in the provision of care.”
  • Contractors can continue other types of inpatient hospital review (i.e. coding reviews, reviews for medical necessity of a surgical procedure, and statutorily mandated therapy reviews).
  1. A timely example of a surgical procedure review is the new issued posted on the Region C Recovery Auditor (Connolly) website on 10/23/13. Connolly has been approved to conduct Medical Necessity “condition of coverage” reviews for major joint replacement (complex review for inpatient claims) and Physician reviews.
  • Contractors can and are directed in the transmittal and “should” continue inpatient hospital reviews for admission prior to 10/1/13 “based on the applicable policy at the time of admission.”

At the end of the day, Contractor “can not’s” is a much smaller subset of inpatient claims submitted for payment by hospitals at risk for review by Contractors. Hospitals need to continue their 2-Midnight Inpatient Admission and Medical Reviews Guidelines implementation and continue to monitor the Hospital Review page on the CMS website frequently for updates.

Link to Inpatient Hospital Review page:  http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/InpatientHospitalReviews.html

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-two years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it.This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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