CMS shifts claim reviews from QIOs to FIs, MACs

Change will mean efficiency, consistency, it says

Citing improved efficiency and consistency, the Centers for Medicare & Medicaid Services (CMS) has begun transitioning the handling of hospital claim reviews from quality improvement organizations (QIOs) to fiscal intermediaries (FIs) and Medicare administrative contractors (MACs).

FIs and MACs are tasked with preventing improper payments, while improper payments will be measured by CMS' Comprehensive Error Rate Testing program (CERT).

According to CMS, the transition will also free up QIOs to focus on quality of care improvement issues and provider assistance efforts.

CERT began reviewing acute care hospital claims for improper payment measurement in April 2008, and will review claims submitted from April 1, 2008, and beyond. FIs and MACs began shortly afterward reviewing acute care inpatient hospital claims for improper payment prevention and reduction, and will review claims submitted from Jan. 1, 2008, and beyond.

"This is significant in that hospitals will now need to call their FI rather than their QIO for some specific topics," according to Jackie Birmingham, RN, MS, CMAC, VP Professional Services for eDischarge, Curaspan Health Group Inc., in Newton, MA.

FIs and MACs began education efforts along with the reviews that commenced in the summer. Experts warn that the shift will mean that statistics generated after the transition won't be accurately comparable to previous sets of statistics.

QIO responsibilities changed

Until recently, QIOs were responsible for Hospital Payment Monitoring Program (HPMP) reviews, including utilization reviews for payment purposes and accuracy measures of Medicare payments for short- and long-term acute care hospitals; quality of care reviews for Medicare beneficiaries; provider-requested, higher-weighted diagnosis-related group (DRG) reviews; and EMTALA reviews.

Prior to the transition, FIs and MACs had no acute care hospital claim review duties, and the CERT program wasn't responsible for measuring improper payments involving acute care inpatient claims.

Under the new system, QIO focus shifts to quality improvement. QIOs will continue to conduct quality reviews, some utilization reviews, and expedited determinations. FIs and MACs will perform most utilization reviews in the new process.

CMS cites three main benefits to the change in review-handling:

  • Consistency in having all Medicare fee-for-service (FFS) settings reviewed by FIs and MACs (Acute long- and short-term hospitals were the only FFS sites not reviewed by FIs and MACs.)
  • Efficiency in having the same entities that process claims responsible for preventing improper payment. CMS believes the new designation of responsibility will also be a cost-saving measure.
  • Lessened perception of conflict of interest raised when QIOs measured the payment error rate for claims on which they themselves made payment determinations.