Medicare Compliance & Reimbursement

QIO can't furnish beneficiary risk certification required for review.

The number of work-intensive expedited reviews home health agencies encounter may be lower than expected, thanks to a change of heart from the feds.
 
Quality improvement organizations' physicians won't be furnishing beneficiaries with certifications that the lack of continued home care would place the beneficiary's health at significant risk, the Centers for Medicare and Medicaid Services says in a question-and-answer posted this month.
 
That's big news because beneficiaries require such certification to proceed with the expedited review process.
Under those reviews, HHAs have to issue a second-step, detailed expedited review notice to the beneficiary explaining why Medicare services are ending.
 
Then they must copy records and send the documentation to the QIO, all by the end of the day of notification.
 
In earlier instructions to intermediaries and in the June 20 special Open Door Forum on the topic, CMS said QIO docs could furnish the cert. But now CMS says "it is not appropriate for a QIO to provide both the physician certification statement required in order to request a review and conduct the actual review of the case," according to the Q&A.

CMS Wants Attending Physician Request

"Instead ... the QIO should instruct the beneficiary of the need to either call his or her attending physician to request such a statement or to obtain the required statement from any other physician of the beneficiary's choice," CMS instructs.

"I am very glad to see that CMS has backpedaled on this issue," says Burtonsville, MD-based health care attorney Elizabeth Hogue.

"It is a fundamental conflict of interest for QIO physicians to provide the certification required and for the QIO ... to review the coverage issues," says Hogue.