In conducting claim review, the BFCC-QIO requests medical records from providers to review medical coding and/or adherence to Medicare regulations for the purpose of validating Medicare claims and payments. These reviews include Short Stay and Higher Weighted Diagnosis-Related Group (HWDRG) reviews. Other types of claim reviews may be added as directed by CMS.
Claim reviews stem from the care provided in acute care facilities including hospitals, psychiatric hospitals, and long-term acute care (LTAC) hospitals.
Hospitals paid under PPS may request a higher weighted DRG payment when the hospital determines that the DRG originally submitted by the hospital was not sufficient based on clinical circumstances. These hospital-requested reviews are performed post payment. A medical necessity review and DRG validation are performed to ensure that the diagnoses, procedures, and discharge status of the patient, as coded and reported by the hospital on its adjusted claim, are supported by the documentation in the medical record.
Hospital admissions with a length of stay less than two midnights are subject to a short stay review. These reviews are conducted on post-payment Part A claims for appropriateness of inpatient admission under Medicare’s Two-Midnight Rule for acute care inpatient hospitals, long-term acute care hospitals, and inpatient psychiatric facilities.
Livanta is authorized to conduct claim review services for CMS on a nationwide basis. All ten CMS regions are within the scope of this contract.