ED Coding and Reimbursement Alert

You’ll be getting medical reviews from a new entity for 2016. CMS has proposed to switch from Medicare Administrative Contractors (MACs) to Quality Improvement Organizations (QIOs) to provide the first line medical reviews regarding questioned admissions.

QIOs, private contractors charged with monitoring the quality of care provided to Medicare beneficiaries, are a good choice for first line reviews as they (in their various program incarnations), have generated a respectable track record across numerous clinical review issues for more than 30 years, says Michael Granovsky, MD, FACEP, CPC, President of LogixHealth a national ED coding and billing company based in Bedford, MA. Quality Improvement Organizations historically have not been involved in enforcement actions and have more collaborative relationships with providers than the RACs which are incentivized by finding errors in audits.

The proposed rule states that reassignment of inpatient admissions to Quality Improvement Organizations will take effect October 1, 2015, even if the other modifications to the two-midnight rule are not implemented. RACs will remain authorized to review hospitals with consistently high rates of denials from Quality Improvement Organizations, notes Granovsky.

CMS is continuing to limit RAC authorities in response to provider objections and the unreasonable multi-year backlog of RAC appeals at the Administrative Law Judge level. Among the proposed changes are:

• Reduce the RAC’s “look back” period to six months for patient status reviews.
• Reduce burdensome documentation requirements
• Impose deadlines of 30 days on complex reviews or RACs lose potential contingency fees
• Impose a 30-day hold before RACs instruct MACs to recoup claim payments.