Providers determine audit areas and number of case request

Introducing the gatekeepers of patient status audits – the Beneficiary & Family Centered Care-Quality Improvement Organizations (BFCC-QIOs). These Quality Improvement Organizations (QIOs) now conduct inpatient short stay reviews for compliance with inpatient medical necessity. If there is non-compliance they refer the provider to the Recovery Audit Contractor (RAC).

As a result of process changes to the inpatient hospital reviews, BFCC-QIOs have been directed to focus on conducting initial patient status reviews of inpatient short stay claims. This focus is on claims in acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities.  In the past, the Recovery Audit Contractors (RACs) have had the responsibility of auditing in this space, but this now falls to the BFCC-QIOs. The BFCC-QIOs’ reviews were put on hold back in May 2016 to educate providers. Now that re-education has occurred, the inpatient short stay reviews have resumed and record request volume process changes have been instated. Providers fall into one of five unique BFCC-QIO audit areas across the U.S. and could be susceptible to 25 or 10 case request based on prior audit findings.

If a provider is found to have consistent high denial rates, a BFCC-QIO can refer a provider to that respective provider’s RAC for non-compliance.  With the BFCC-QIOs now acting as a gatekeeper to the RACs, it is imperative that providers pay attention and respond to any notice from their BFCC-QIO.

Providers can expect to be dealing with a smaller volume of requests within an audit. However, this shrink in volume comes at a cost—there is a smaller margin of error. Download our infographic to understand BFCC-QIO involvement including the look-back period, the frequency of request, the selection process, and your BFCC-QIO area.