CMS issues more information on pause of QIO two-midnight review

The Centers for Medicare & Medicaid Services has provided additional information on its temporary pause of Quality Improvement Organization claim audits under the two-midnight inpatient admissions policy. During the pause, which began May 4, CMS will improve standardization around the QIO review process. This will include retraining the QIOs on the two-midnight policy, a re-review of claims denied by the QIOs and any needed provider outreach and education. CMS advises hospitals to work with their QIOs to determine whether denied claims have been re-reviewed prior to appealing a claim denial. If a denied claim has been appealed and upon re-review the QIO determines it was denied inappropriately, the QIO will share its re-review findings with the appeals adjudicators to be taken into consideration during the appeal process. CMS anticipates that QIOs will resume audit activities within 60-90 days, but will formally advise stakeholders once the pause is lifted. CMS also released a Policy Decision Guideline flowchart that will be used to guide QIO determinations under the two-midnight policy. CMS initiated the pause after AHA staff shared with the agency hospitals’ concerns about the QIO review process.