CMS announces process change for short-stay inpatient claim reviews in Medicare

Recent CMS directives for hospitals include a process change regarding Medicare patient status reviews.

Beginning Sept. 1, Medicare administrative contractors (MACs) will conduct the reviews used to determine the appropriateness of Part A payment for adjudicated short-stay inpatient hospital claims. The reviews to date have been conducted by Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs), although MACs have had responsibility for following up with providers, as needed, about payment recoupment and education on criteria for inpatient stays.

“While this change impacts where medical record requests will be sent and the contractor making claim review decisions, the policy for assessing short-stay inpatient admissions remains unchanged,” CMS said in the announcement.

It remains to be seen, however, whether the change affects the speed and efficiency of the review process.

The change likely stems, at least in part, from previously announced personnel reductions at HHS. With a decrease of 300 jobs out of roughly 6,500 at the agency, CMS largely was spared from staffing cuts that totaled 20,000 across HHS. But contracted roles with provider-facing functions were considered more vulnerable.

Scrutiny on gender transition procedures

In others news, CMS has announced increased oversight of hospitals that perform gender transition procedures on minors.

A letter signed by CMS Administrator Mehmet Oz, MD, and sent to certain hospitals, requests information that includes all billing codes used for pediatric sex-trait modifications, including those that correspond with procedures not determined to be medically necessary. According to guidance released in recent weeks by HHS, puberty blockers and hormone therapies are among such procedures.

Hospitals also are supposed to send financial data relating to the procedures in question, specifically data on facility- and provider-level revenues and operating and profit margins, along with revenue forecasts for the pertinent service lines.

Data to be supplied on quality-related protocols includes the adequacy of informed-consent processes, planned changes to clinical practice guidelines in response to HHS’s newly updated guidance, and any adverse events related to these procedures, including in children who later look to de-transition.

CMS expects to receive the requested responses within 30 days of the May 28 letter, which does not refer to potential consequences for noncompliance with the request.

“CMS takes these matters extremely seriously,” Oz wrote. “Our primary concern is ensuring that vulnerable pediatric populations receive evidence-based care that meets the highest quality standards while ensuring appropriate stewardship of federal healthcare resources.”

An appendix to the letter includes the six ICD-10 codes and dozens of procedure codes that may be associated with medical interventions for gender dysphoria in minors.