Helpful things to know

Here are some helpful things to know:

• First, the BFCC-QIO will decide if your concerns may be handled through “Immediate Advocacy”, or through a formal quality of care review process.
  • A Medicare beneficiary can agree to participate in a process called Immediate Advocacy with his/her health care provider to get an answer to a concern quickly.
  • Immediate Advocacy is an informal process the BFCC-QIO uses to quickly resolve a verbal complaint.
  • When you or your representative agree to it, the BFCC-QIO immediately contacts your doctor or health practitioner directly on your behalf, usually by telephone.
  • The process is totally voluntary for both the beneficiary and the provider or practitioner.

• Examples of complaints that may be resolved through Immediate Advocacy include (but are not limited to):​
  • Complaints about a lack of communication by hospital staff 
  • Concerns about the failure to receive a motorized scooter, wheelchair, or another piece of equipment
  • Difficulty scheduling an appointment for a prescription refill

• If you make a formal quality of care complaint, your BFCC-QIO will request your medical records and forward them to a practicing doctor who works for the BFCC-QIO. This doctor will independently review your medical records, look at all aspects of the care you received and communicate with the medical professionals involved in your care. This process may take some time.
• Depending on the BFCC-QIO doctor’s findings, the BFCC-QIO will decide how to address and resolve the complaint.
• Except in the most serious situations, the purpose of a medical review is not to penalize or punish your doctor, hospital or other health care providers. The purpose of the BFCC-QIO review is to help doctors and health care providers improve the future care they give to people with Medicare.
• Important Guidance Related to Inpatient Hospital Reviews

• CMS established the 2-Midnight rule in the FY 2014 Hospital IPPS Final Rule published on August 19, 2013 (78 FR 50495) to provide additional clarity regarding when an inpatient admission is payable under Part A.  Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) contractors began post-payment review of Short Stay Hospital inpatient claims in 2015.  In May 2016, CMS published the BFCC-QIO 2 Midnight claim review guideline.  In February 2021, Livanta was awarded the contract for performing claim reviews for Short Stay and Higher-Weighted Diagnosis Related Group (HWDRG) claims in all U.S. states and territories. Click here for more information.

Attached below is a historical reference and claim review guideline related to the Beneficiary and Family Centered Care Quality Improvement (BFCC-QIO) contractor post-payment review of Short Stay Hospital inpatient claims.  This document may serve as helpful resources for other CMS claim review Contractors, Hospitals, Admitting Physicians and Practitioners.