CMS considers a short hospital stay to be one with a length of stay that is less than 2 midnights after inpatient admission. CMS will monitor the number of these types of admissions and may prioritize these types of cases for medical review.

The term “short stay patient status review” refers to medical record reviews conducted by Medicare contractors to determine if inpatient admissions are appropriate for Part A payment.

To prevent improper payments and protect the Medicare Trust Fund, CMS contracts with a variety of contractors to conduct medical review. The MACs are one type of contractor that conducts medical review. They collect and conduct clinical review of medical records and related information to ensure that payment is made only for services that comply with Medicare requirements.

Currently there are 12 Medicare Part A and B MACs who will assume this workload. For a complete listing of the MACs see: https://www.cms.gov/medicare/coding-billing/medicare-administrative-contractors-macs/who-are-macs.

Transitioning this work to the MACs allows the BFCC-QIO to expand quality of care review efforts to other areas. Specifically, this change allows the BFCC-QIO program to focus its efforts on quality improvement initiatives including continuing its quality review work, expedited appeals determinations, and certain utilization reviews, such as provider-requested higher-weighted Diagnosis Related Group reviews and referral evaluations.

For more information about the BFCC-QIO program, see: https://www.cms.gov/medicare/quality/quality-improvement-organizations/family-centered-care.

BFCC–QIO will continue to review post-payment inpatient hospital claims for higher weighted Diagnosis Related Groups, hospital discharge and service termination appeals, and quality of care concerns. The BFCC-QIO is statutorily required to determine the medical necessity of the admission (see Social Security Act, section 1154(a)(1)(A) and section 1862(a)(1) and (9)). While the BFCC-QIO will not specifically select short stay claims for the purpose of assessing compliance with the two-midnight rule, if the BFCC-QIO encounters a hospital short inpatient stay claim when reviewing for other reasons, the medical record will also be reviewed for compliance with the two-midnight rule.

Inpatient short stay reviews will mirror the existing TPE process already familiar to Part A and B providers. When performing medical review as part of TPE, MACs focus on specific providers that bill a particular item or service rather than all providers billing a particular item or service. MACs will focus only on providers who have been identified through data analysis as being a potential risk to the Medicare trust fund and/or whose billing patterns vary significantly from their peers. TPE typically involves the review of 20-40 claims per provider, per item or service. In some instances, for providers with lower billing volumes, a smaller sample of claims may be requested. This is considered a round, and the provider has a total of up to three rounds of review. After each round, providers are offered individualized education based on the results of their reviews. Providers are also offered individualized education during a round when errors that can be easily resolved are identified. 

For more information on the MAC TPE Program see:  https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/targeted-probe-and-educate-tpe.

No, as indicated above, the TPE program is a targeted review approach that focuses only on providers who have been identified through data analysis demonstrating aberrant billing patterns that indicate the need for review and education.

MACs will generally (per their usual TPE process) conduct the reviews on a prepayment basis. We note that prepayment review has historically been provider preferred (for financial predictability/to avoid returning previously received payment) and is additionally beneficial for patient status reviews as timeliness is essential for A/B rebilling (i.e., the process where providers who are denied Part A payment receive partial payment under Part B).

MAC TPE program details are summarized below: 

Hospital patient status review work will transition back to the MACs. This will require hospitals to incorporate internal changes to ensure requested medical records are submitted to the appropriate MAC rather than the BFCC-QIO. MACs will work closely with the provider community to ensure understanding of the appropriate processes that should be followed to ensure a seamless transition of this work. 

There is no change in regulatory policies being applied to hospital patient status reviews. Transition of this work to the MACs will not impact CMS’ long-standing emphasis on the importance of a physician’s medical judgment in meeting the needs of Medicare beneficiaries. Therefore, we do not anticipate significant impact on hospitals or beneficiaries.

. CMS developed a detailed transition plan with the BFCC-QIO and MAC organizations that will include educational programs to ensure a successful transition for our beneficiary and provider communities.

Providers will receive additional education and training via Medicare Learning Network (MLN) Matters, provider bulletins and articles from CMS and local MACs. Before this transition occurs, CMS and the MACs will ensure providers understand the TPE process and how to submit medical record documentation to the MACs. MACs will also ensure providers receive contact information to direct questions or concerns related to this transition.

MAC hospital patient status reviews will be performed by Registered Nurses. However, MAC Medical Directors will serve as a readily available source of medical information to provide guidance in questionable claims review situations. As with all other Medicare claim types, MACs are not required to use physicians to review every inpatient hospital claim.

MACs are required to maintain a quality assurance program for all medical review program activities. CMS conducts special and regularly scheduled quality assurance activities to monitor the quality and accuracy of MAC medical review program activities and clinical determinations. 

As indicated in the Hospital OPPS Final Rule 1633-F, CMS does not mandate the use of such tools, nor is it necessary for a beneficiary to meet an inpatient “level of care,” as may be defined by a commercial screening tool, for Part A payment to be appropriate. 

MACs will not be using screening tools as part of their review. CMS expects MACs to evaluate hospital patient status documentation to ensure patient medical records provide detail of the patient’s condition and support the need for services to be provided in an inpatient hospital setting in accordance with 42 C.F.R. § 412.3(d). The MACs will rely on the documentation found in the medical record and their clinical expertise to determine if Part A payment is appropriate in accordance with CMS regulations.

No, the MACs will continue to follow regulatory guidance in accordance with 42 C.F.R. § 412.3. A general outline of the review policy and process has been updated to reflect that hospital patient status reviews will be performed by MACs, and a guideline outlining the MAC review determination process will be available in a future update of the Program Integrity Manual 100-8 Chapter 6 and in the exhibit section.

MACs do not reimburse photocopy/electronic record transfer costs for any provider in any setting. Consistent with current MAC practice for all other provider types, MACs will not reimburse providers for the cost of copying/transferring medical records.

. No, there is no formal rebuttal process within the TPE process; however, when MACs may identify errors in the claim(s) that can be easily cured during the course of a provider’s probe reviews, they will offer the provider an opportunity to do so. Easily curable errors include, but are not limited to, missing documentation that can be resolved through the submission of additional documentation and missing signatures that can be resolved with a signature attestation. When the MAC identifies an easily curable error, the MAC will contact the provider to address the error and allow the provider to submit missing documentation, etc. This will help providers avoid denials and similar errors later in the process. CMS’ experience has shown this educational approach is well received by providers and helps to prevent future errors. 

In the event an error cannot be cured during the TPE process, providers and beneficiaries may exercise their appeal rights as described below.

Q. What appeals process will be used should a provider disagree with the MAC claim decision?

A. No changes to the current appeal process are anticipated. Once an initial claim determination is made, any party to that initial determination, such as beneficiaries, providers, and or their respective appointed representatives – has the right to appeal the Medicare coverage and payment decision. For more information on who is a party, see 42 CFR 405.906.

Section 1869 of the Social Security Act and 42 CFR part 405 subpart I contain the procedures for conducting appeals of claims in Original Medicare (Medicare Part A and Part B).

There are five levels in the Medicare Part A and Part B appeals process. The levels are:

For more information on the Medicare appeals process please see:  https://www.cms.gov/medicare/appeals-grievances/fee-for-service.

Q. What is the Centers for Medicare and Medicaid Services (CMS) announcing?

A. On 5/22/25, CMS notified the public that Medicare Administrative Contractors (MACs) will perform short stay inpatient hospital medical reviews and provider education (i.e. patient status reviews). This type of review was previously conducted by the Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization (QIO) (BFCC-QIO). The BFCC-QIO is currently conducting reviews; with an anticipated ending of medical review activities in August 2025.

Q. When will MACs assume responsibility for these types of reviews?

A. The MACs will assume responsibility for conducting initial patient status reviews no earlier than September 1, 2025. 

Q. What is the purpose of this type of MAC medical review and provider education? 

A. The purpose of this type of medical review activity is to determine the appropriateness of Part A payment for short stay inpatient hospital claims and when warranted offer provider education. 

Q. Will transition of this work from the BFCC-QIO to the MACs have a significant impact on Inpatient Hospital providers and beneficiaries?

A. MACs will conduct patient status reviews in accordance with established CMS policy. CMS believes this change will have minimal impact on providers and beneficiaries since there has been no change in policy.

Q. What process will the MAC use to conduct these reviews? 

A. MACs will utilize the Targeted Probe and Educate (TPE) program to conduct Short Stay patient status reviews.  This program allows providers to benefit from one-on-one education, and when applicable, intra-probe education and intervention to correct easily curable errors. For more information on the TPE program, please see:  https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/targeted-probe-and-educate-tpe.

Q. Does CMS plan to provide additional educational materials and provider education? When will CMS post additional information regarding transition of this work to the MACs?

A. Yes, CMS and the MACs will provide additional detailed information regarding the transition of patient status reviews at a later date.