SPRING
2015
ISSUE
No. 2

CASE REVIEW
CONNECTIONS  
          
Welcome to Case Review Connections!
Case Review Connections has been published to provide you with information from KEPRO, your Beneficiary and Family Centered 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.

Expedited Determinations

When is a Notice of Medicare Non-coverage (NOMNC) not required?    

 
When:

  • A beneficiary never received Medicare-covered care in one of the covered settings (for example, an admission to a skilled nursing facility [SNF] will not be covered due to the lack of a qualifying hospital stay, or a face-to-face visit was not conducted for the initial episode of home health care);
  • Services are being reduced (for example, a home health agency [HHA] providing physical therapy and occupational therapy discontinues the occupational therapy);
  • Beneficiaries are moving to a higher level of care (for example, home health care ends because a beneficiary is admitted to a SNF);
  • Beneficiaries exhaust their benefits (for example, a beneficiary reaches 100 days of coverage in a SNF, thus exhausting their Medicare Part A SNF benefit);
  • A beneficiary transfers to another provider at the same level of care (for example, a beneficiary transfers from one SNF to another while remaining in a Medicare-covered SNF stay); or
  • A provider discontinues care for business reasons (for example, an HHA refuses to continue care at a home with a dangerous animal).
Tips for Success
  • For hospice appeals, please include documentation that supports the reason for admission, rationale for discharge from hospice; SERIAL measurable clinical information such as Karnofsky Scale, FAST, Palliative Performance Scale, and IDT notes for the last two certification periods.
  • Please make sure that you are using the most updated Notice of Medicare Non-coverage - CMS 10123, Approved 12/31/11.
  • Please make sure that after hours and weekend staff are trained about the appeals process.
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.
 

SNF Immediate Advocacy Success Story

A beneficiary's husband contacted the BFCC-QIO with concerns about his wife's home health services. His wife was receiving home health services four times per week for blood pressure and vital sign checks. He explained to the Intake Specialist that he is performing these services for his wife and did not feel that home health services were necessary. He felt it was disruptive, and he did not want to continue to be billed. He had requested four times in the last several weeks for the services to stop, and the home health agency continued to come out to his house. She is under care with a liver specialist and a primary care physician. The Intake Specialist agreed to make calls to the home health agency to find out the beneficiary's status and express the husband's desire for discharge.    
                                                                                             
headset-woman.jpgA phone call was made to the Director of Nursing at the home health agency. She stated that she had a nurse's note from the week prior with a request for the discontinuation of services. She did not show any entries from prior to that time. She explained that the beneficiary was receiving education and supportive care regarding her disease process (liver disease). The agency had received the physician orders for discharge that week and planned to have a nurse go out that day with the discharge explanation and to obtain signatures from the beneficiary and her husband. The Intake Specialist left a message for the beneficiary's husband about the planned discharge. A return phone number was left if he had any questions.
 

Peer Reviewer Recruitment

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

 

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.

Sub-Acute FAQs

Q. If the home health agency issues the non-coverage letter two visits or days before the service ends and the patient postpones the last visit or day, does the agency need to issue a new letter to reflect the new day?

 

A. The simple answer is "no." The home health agency has given the beneficiary an advanced notice indicating that Medicare payment for skilled services will end on a certain date. Should skilled services continue beyond the EFFECTIVE DATE on the Notice of Medicare Non-coverage (NOMNC), the patient may be financially responsible for those services. The NOMNC is given on the next-to-last visit, which is typically at least two days (fulfilling the federal requirement) between the visit and the EFFECTIVE DATE.

Q. Does KEPRO get involved in cases in which a beneficiary is sent to a nursing home, but it is not covered because he or she was not admitted for the required three days because he or she was under observation status?

 

A. Observation status is determined by the attending physician at the hospital. It would not be appropriate for KEPRO to advocate for a change in admission status. Beneficiaries are informed before going to the nursing home whether coverage will be available under Medicare. They are able to make the choice about whether they wish to be private pay.

Educational Presentations

Recently, KEPRO was able to provide an educational presentation for a provider. It was very well received. If your facility is interested in having a presentation by webinar, 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
 
    
  
      
Publication No. A234-136-5/2015. 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.