Hospitals are once again adjusting to a new chapter in Medicare oversight. As of September 1, 2025, Medicare Fee-for-Service short stay reviews officially transitioned from the Quality Improvement Organizations (QIOs) to Medicare Administrative Contractors (MACs).
The shift in who performs the reviews has major implications for hospitals, especially regarding compliance, prepayment scrutiny, and financial exposure.
What This Change Means for Hospitals
Under the new process, MACs will manage short-stay reviews with a more data-driven, prepayment focus. That means hospitals could see an increase in review frequency and more targeted audit activity based on billing trends.
Here’s what you can expect:
- Reviews will be prepayment, not post-payment, which can delay reimbursement if documentation is incomplete or unclear.
- MACs will use data analytics to identify hospitals with billing patterns that differ from peer benchmarks.
- The two-midnight rule remains the guiding standard for inpatient payment eligibility.
- Hospital stays longer than two midnights after formal admission are presumed reasonable and necessary for Part A payment.
- Shorter stays will remain under the microscope, particularly when data suggests potential overuse or noncompliance.
With MACs assuming responsibility for these reviews, the takeaway is clear: hospitals must ensure a robust, proactive short stay review process to stay compliant and protect revenue.
Why Certus Radar™ Is the Right Solution—Right Now
Certus Radar™ Automated Medicare Short Stay (Self-Denial) Solution helps hospitals manage the complexities of short stay compliance. Given the September 2025 transition, its value is greater than ever.
Certus Radar™ automates the review and self-denial process, helping hospitals identify, assess, and correct short stay cases before billing—minimizing risk and supporting accurate patient status determination.
How Certus Radar™ Protects Your Hospital
Ensure CMS Compliance: Stay aligned with CMS requirements, including the two-midnight rule and self-denial/rebilling pathways, even under MAC review.
Reduce Denial Risk: Identify short stay cases proactively to prevent costly denials, reduce administrative burden, and protect reimbursement.
Strengthen Audit Readiness: Prepare for MAC, RAC, and TPE reviews with better documentation accuracy and consistent prebilling review processes.
Support Patient Confidence: Accurate status and billing decisions to prevent confusion, unexpected costs, and downstream appeals—supporting a better patient experience.
Staying Ahead of MAC Oversight
The transition to MAC-led short stay reviews signals a more targeted, data-informed oversight era. Hospitals that rely on manual or fragmented review processes will face a greater risk of prepayment denials and audit delays.
With Certus Radar™, your organization gains the automation, visibility, and assurance needed to stay compliant, reduce risk, and stay off the radar.
Learn how Certus Radar™ can strengthen your Medicare Short Stay (Self-Denial) compliance process.
