Ask the Payment Expert about ... expedited review
Ask the payment expert ... about the observation stay loophole
A facility recently had a resident request an expedited review. The outcome of the review was an agreement with the facility discontinuing skilled services. Then the resident appealed the decision and it was overturned by the Qualified Independent Contractor. What does that mean for the facility?
The expedited review process was developed so a resident could quickly appeal the process if he or she disagreed when a facility decided that a resident is no longer covered under skilled services.
The resident request must be made by noon on the day prior to the day of discontinuation. The Quality Improvement Organization decision is usually made within 72 hours. If the decision is that the coverage should continue, the resident can continue a covered stay and the continuation of services.
The QIO will notify the resident of its decision. The resident can then appeal if he or she disagrees. This is considered a second level of appeal and is made to the Qualified Independent Contractor.
This process also is an expedited review and the QIC decision should come within 72 hours. The resident can ask for a process delay of up to 14 days if time is needed to gather information or get documents from the facility, a physician or other providers.
In the scenario questioned above, the decision of the QIC to overturn the QIO finding would be binding, the same as if the QIO had made that decision. So, in effect, the facility should continue with the coverage until it again feels the skilled services should be discontinued and it could not have that decision overturned by medical review.
It is actually to the facility's advantage to make sure residents know the steps of the expedited review process and to assist them in the process.