Spring
2015
ISSUE
No. 2

CASE REVIEW CONNECTIONS
smiling-computer-ladies2.jpg   
Welcome to Case Review Connections!
Case Review Connections has been published to provide you with information from KEPRO, your Beneficiary and Family Centerd Care Quality Improvement Organization (BFCC-QIO). We welcome your feedback at KEPRO.Communications@HCQIS.org to learn more about topics that interest you.
Medical Director's Corner - Ferdinand Richards III, MD

I want to thank our providers for their assistance during the recent transition from state-based Quality Improvement Organizations (QIO) to KEPRO, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). At this point in the contract (month 10), we are confident that we have a robust Peer Reviewer panel who are providing quality and timely reviews. Our Peer Reviewers are spread across all three of our geographic areas, ensuring a localized presence. To make sure that our reviews are completed properly and in accordance with evidence based on medical practice and utilization guidelines from the Centers for Medicare & Medicaid Services (CMS), we are focused on education for our Peer Reviewer panel. We have three primary modes for Peer Reviewer education: web portal, conference calls, and one-on-one feedback.

Our staff of medical directors oversees the peer review process. The oversight process includes inter-rater reliability (IRR), monthly review audits, and tracking and trending. We value your feedback in this process and look to that input as a barometer of our performance. If you have any questions or feedback, please feel free to contact me at frichards@kepro.com or 813-280-8256, extension 7203.

FAQs - Hospital

Q. Can decisions about a quality of care complaint or discharge appeal be used in a malpractice lawsuit?

A. The BFCC-QIO's findings are protected by federal rules and regulations governing confidentiality. They are not admissible in a malpractice lawsuit and cannot be released under the Freedom of Information Act (FOIA).

 

Q. If the patient is in the hospital but never truly admitted, could the patient or family still call KEPRO to appeal a discharge from the hospital?
 

A. In order for the Medicare beneficiary to have appeal rights through the BFCC-QIO, he or she must be in an inpatient billing status. Patients who are in "outpatient" or "observation" status are excluded from the BFCC-QIO's appeal process. The Medicare beneficiary should have been given an Advanced Beneficiary Notice (ABN), which outlines his or her appeal rights through the Medicare Administrative Contractor (MAC).

Hospital Discharge Appeals

To expedite the acute hospital discharge review, consider limiting your fax of medical records to the following:

  • Copy of the Important Message from Medicare (IM)
  • Copy of the Detailed Notice of Discharge (DND)
  • Copy of the beneficiary's medical record to include the following elements for the first 48 hours and the last 72 hours:

 

Inpatient Order and Attestation

Consults

Ancillary Results

History & Physical

Nurse's Notes

 

 

Physician Orders

SS/CM Discharge Planning Notes

 

 

Physician Progress Notes

PT/OT Evaluation and Notes

 

 

 
  • Please use your professional judgement and send ONLY documentation that is pertinent to this admission.
  • Be sure there is an inpatient admission order. If the patient is in observation status, the documentation of this status and the patient face sheet are all you need to fax.
  • Is the discharge plan to another acute facility? The documentation of this plan or order and the patient face sheet are all you need to fax.

If there is NO planned discharge, then fax the patient face sheet with the second page of the KEPRO expedited appeal documentation request. 

  • Is the discharge plan to a skilled nursing facility? Be sure to provide documentation of a confirmed accepting facility.
  • Include the Hospital Issued Noticed of Non-coverage (HINN) if the review is for Admission Denial or Hospital Requested Review (HRR).

Hospital Immediate Advocacy Success Story

Immediate Advocacy is a process that CMS makes available for beneficiaries to resolve an oral complaint, if the complaint is received within six months from the date of service. If the Medicare beneficiary or representative gives verbal consent for this process, the QIO Intake Specialist contacts the provider or practitioner on behalf of the beneficiary.

This process can provide a more appropriate, flexible approach to resolving complaints in situations  that are not suitable for the traditional peer review process.

Sometimes the success of the process is in all the parties having tried their best and talked over the issues to fully air each perspective. This was the outcome with a beneficiary who was in the hospital for cardiac treatment. He had filed a discharge appeal and was transferred to the Helpline to report mistreatment and disrespect from a physician and two nurses. He felt the stress of the situation was making his cardiac condition worse. The Intake Specialist agreed to contact the Patient Advocate at the hospital about the beneficiary's concerns.

Our Intake Specialists come to recognize that there is always more than one perspective on any difficult situation. The hospital's Patient Advocate reported that the case manager, charge nurse, and several others had spent over four hours with the beneficiary on the previous day. The physician had also gone in on the previous evening to apologize to the beneficiary for any misunderstandings and to acknowledge his concerns. The Patient Advocate agreed to visit the patient again to explain that the hospital staff is continuing to work on the issues that he brought to their attention. She was appreciative of the BFCC-QIO's call.

The Patient Advocate contacted the patient and physician again, reviewed the documentation of  the time staff had spent working to resolve the beneficiaries concerns, and reported back to our Intake Specialist. The Patient Advocate felt that they had reached out in every way to address the beneficiary's concerns. She let him know that they would continue to provide all care needed pending the outcome of the discharge appeal. The BFCC-QIO Intake Specialist left a voicemail for  the beneficiary advising him of the outcome/resolution of his complaint, and a return phone number if he had any questions.

 Quality Improvement Initiatives (QII)

KEPRO has started referrals for QII to state Quality Innovation Network Quality Improvement Organizations (QIN-QIO).

The QIN-QIO will be responsible for the Quality Improvement Activity (QIA) for providers and practitioners when there are confirmed concerns from a quality of care review. Click here to find the QIN-QIO for your state.

 Peer Review Recruitment

KEPRO continues to expand its Peer Reviewer roster for all three contract areas. Opportunities for Peer Reviewers of all different specialties such as advanced nursing, various therapies (physical, occupational, speech), and medicine currently exist.  bronze-medicine-symbol.jpg

 

KEPRO Peer Reviewers:

  • Are offered challenging opportunities to use their medical knowledge to improve the quality of health care;
  • Enjoy competitive compensation;
  • Receive complete confidentiality;
  • Have the convenience of reviewing a case at home or at the office; and
  • Can join a pool of physicians who are leaders in their specialties.

For further information, contact Jessica Whitley, MD, Medical Director, at 216-447-9604, extension 5784, or email Jessica.Whitley@bfcc3.hcqis.org.

 

 Educational Presentations

Recently, KEPRO was able to provide an educational presentation for a hospital. It was very well received. If your hospital is interested in having a webinar presentation, please contact the local Outreach Specialist in your area.

Save the Date!
  
Join us for a BFCC-QIO webinar! We offer information and assistance to providers, patients, and families regarding beneficiary complaints, discharge appeals, and Immediate Advocacy. During the webinar, KEPRO representatives will present an overview of the role of the BFCC-QIO and the services provided.
  
What:  The BFCC-QIO Program
Who:  Healthcare providers and stakeholders
When:  June 17, 2015, 2 p.m. - 3:15 p.m. ET
Speakers:  Nancy Jobe, Outreach Specialist, KEPRO; Jenna Duwenhoegger,
  Outreach Specialist, KEPRO
  
  
Coding Corner
  

The transition to ICD-10 Coding is approaching, with just 5 months preparation and planning time before October 1, 2015. CMS has released 2 new ICD-10 videos and has also released an ICD-10 web-based training course.

Additionally, there are 3 new MLN Connects ICD-10 videos. These are all available at CMS.gov on the ICD-10 tab. There are also many ICD-10 resources available from AHIMA.

For facilities with status questions about specific HWDRG claims, please fax your questions to the attention of Steve Dicksen at 813-282-1505.

 
Publication No. A234-135-5/2015. This material was prepared by KEPRO, a Medicare Quality Improvement Organization under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.