Transition of Short Stay Inpatient Hospital Claim Reviews
Beginning September 1, 2025, the responsibility for conducting patient status reviews concerning short stay inpatient hospital claims under Part A shifts from the Beneficiary and Family Centered Care Quality Improvement Organization to the Medicare Administrative Contractors (MACs). This change means medical record requests and claim review decisions will now be handled by MACs rather than the previous reviewer.
Notably, the fundamental policy for assessing short stay inpatient admissions remains unchanged. This ensures continuity in how inpatient claims are evaluated while consolidating review responsibilities for increased efficiency.
- The change impacts the routing of medical record requests.
- MACs will now make determinations regarding claim appropriateness for short stay hospital admissions.
- Hospitals and providers should familiarize themselves with updated procedures to avoid delays.
- Medicare Shared Savings Program Applications Now Accepted
The Centers for Medicare & Medicaid Services (CMS) has opened the application period for the Medicare Shared Savings Program (MSSP). Interested organizations must apply through the Accountable Care Organization (ACO) Management System by noon ET on June 12, 2025.
The MSSP promotes collaboration between healthcare providers to improve quality and reduce costs in Medicare. Key resources supporting the application process include:
- Application Toolkit for guidance on submissions.
- Application Types & Timeline webpage outlining deadlines.
- Key Application Actions and Deadlines (PDF) for detailed steps.
Applicants with questions can email SharedSavingsProgram@cms.hhs.gov for assistance.
Updates on Coverage and Provider Qualifications
Additionally, two important MLN Matters® articles provide updated guidance relevant to Medicare providers:
- National Coverage Determination 20.36 outlines coverage criteria effective January 13, 2025 for implantable pulmonary artery pressure sensors used in heart failure management. This includes coverage with evidence development criteria and claims processing adjustments by Medicare Administrative Contractors.
- Updates to qualifications for speech-language pathologists delivering outpatient services are detailed in the Medicare Benefit Policy Manual, Chapter 15, section 230.3. These changes align with regulatory standards ensuring provider competency.
CHAMPVA Providers Now Required to Enroll in Electronic Funds Transfer
Providers treating patients under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) are now mandated to enroll in electronic funds transfer (EFT) to receive payments, effective immediately as a federal requirement.
Enrolling in EFT offers multiple benefits:
- Ensures claim payments are secure, efficient, and compliant.
- Helps protect eligible Veterans’ family members’ access to health benefits.
To enroll, providers should:
- Visit the VA Financial Services Center Customer Engagement Portal.
- Complete the Payment Account Setup webform.
- Contact Financial Services Center customer support at 877-353-9791 for assistance if needed.
About CHAMPVA: This program supports qualified spouses, widows/widowers, and children of eligible Veterans by sharing the cost of certain healthcare services and supplies. More information is available on the CHAMPVA–Information for Providers webpage.
“Enrolling in EFT is not optional — it’s a federal requirement that helps maintain payment integrity and protect access to benefits for Veterans’ families,” emphasized federal healthcare officials.
What Providers Should Do Next
With significant changes coming later this year, providers are encouraged to prepare early by:
- Reviewing updated short stay inpatient claim review procedures with their Medicare Administrative Contractors.
- Submitting MSSP applications by the June 12 deadline if interested in the Shared Savings Program.
- Ensuring enrollment in EFT for CHAMPVA to avoid payment disruptions.
- Familiarizing themselves with new Medicare coverage and qualification policies to remain compliant.
Staying informed and proactive will help providers navigate these Medicare updates smoothly and continue delivering quality care.
