No. 3

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 to learn more about topics that interest you.
Medical Director's Corner - Ferdinand Richards III, MD
As providers, you may wonder what KEPRO, as the BFCC-QIO, does with the large amount of data that we collect from the many reviews that are performed. As our name implies, we use data for health care quality improvement. KEPRO tracks and trends data by state, by review type, by outcomes, and by provider. We offer that information to providers as feedback to help with their processes. If a hospital has a large amount of discharge appeals that are overturned, that information will be shared to determine if there is a concern at that facility. If a facility has no appeals at all, the BFCC-QIO may look at whether the notice is being issued correctly.
When doing a quality of care review, the facility may need to do a quality improvement activity if the medical record review identifies a confirmed concern. In that case, the provider may need to have data monitoring, which is done by the Quality Innovation Network Quality Improvement Organization (QIN-QIO). Confirmed concerns are also stored in a database that can be accessed by the Centers for Medicare & Medicaid Services (CMS). KEPRO is currently working on posting its Annual Report. This report will provide information regarding the number of reviews that are being performed along with information about what KEPRO has accomplished with this information. The report will be posted on our website in October.
FAQs - Hospital
Q. During a hospital appeal, when should patient liability start once KEPRO makes the decision?
A. Assuming the request was timely, liability will begin at noon on the day after KEPRO notifies the beneficiary.
Q. Can you give a brief outline of the reconsideration process? 
A. The reconsideration process is the same as the initial appeal, except a different physician is used and there is no protection in place for the financial liability.
Hospital Discharge Appeals
Hospitals must issue the Important Message from Medicare (IM) within 2 calendar days of the day of admission. The staff must obtain the signature of the beneficiary or his or her representative to indicate that he or she received and understood the notice.
The IM, or a copy of the IM, must also be provided to each beneficiary within 2 calendar days of the day of a hospital discharge. Thus, in cases where the delivery of the initial IM occurs more than 2 days before discharge, hospitals will deliver a follow-up copy of the signed notice to the beneficiary as soon as possible prior to discharge, but no more than 2 days before. For beneficiaries who request an appeal, the hospital or health plan, if applicable, will deliver a Detailed Notice of Discharge.
If a beneficiary is in observation status or in the emergency department, the IM should be given within 2 calendar days of the actual admission to the inpatient hospital level of care.
Regulations require that the follow-up copy of the IM be delivered as far in advance as possible, but no more than 2 days prior to discharge. When a hospital can anticipate the discharge, it should give the follow-up copy of the notice 1 or even 2 days before discharge. When the hospital cannot anticipate the discharge, it should deliver the follow-up copy as soon as the discharge can be anticipated.
A follow-up copy is not required prior to transfers from one inpatient hospital setting to another inpatient hospital setting, for example, a short-term acute care hospital to a long-term acute care hospital. When a beneficiary is transferred to another inpatient hospital setting, the notice delivery time frames start again. Thus, the receiving hospital must issue an initial IM within 2 calendar days of the day of admission and a follow-up copy no more than 2 days prior to the day of discharge.
A follow-up copy of the signed notice is required prior to discharge to a lower level of care, such as a swing bed or skilled nursing facility.

Hospital Immediate Advocacy Success Story

Immediate Advocacy - an informal process in which the BFCC-QIO acts as a liaison for the Medicare beneficiary to quickly resolve an oral complaint.
A beneficiary contacted the BFCC-QIO with concerns about the cancellation of a kidney transplant. He was told that he was non-compliant with after-care requirements by the staff at the transplant center, but he did not agree. He was upset and did not know what to expect regarding moving forward.
The Intake Specialist contacted the social worker at the hospital, as the case coordinator was out of town. The social worker stated that she had spoken with the beneficiary at great length regarding the issues surrounding the transplant procedure. The social worker explained that the beneficiary had to have a caregiver 24/7 and had to have access to reliable transportation twice a week for follow-up appointments, to make sure that the organ was not being rejected. The nephrologist and the surgeon made the decision not to proceed with the procedure based on the lack of a reliable transportation plan. However, he could be considered again once a proven transportation plan is in place, so the staff could be assured of a greater likelihood of a successful transplant. The social worker agreed to follow up again with the beneficiary, to again explain the reason for the cancellation and the options for a future transplant.
The beneficiary was also contacted again by the Intake Specialist. He was still not in agreement but did appreciate the contacts. He was also told that the case coordinator would also be in touch with him along with the social worker at the facility.

 Reminder: Upcoming BFCC-QIO Changes

The Centers for Medicare & Medicaid Services (CMS) is implementing changes for all quality of care reviews.
  • Providers will soon have 14 days (they're currently allowed 30 days) to send in the medical record once a medical record request is received. Because of these tightened time frames, we are encouraging providers to fax medical records to KEPRO rather than sending them via mail. The quality of care department at KEPRO has its own dedicated fax number, which will be listed on the medical record request.
  • After the medical records are received, KEPRO has 30 days to complete the review. Providers that wish to provide a response when they receive an inquiry from KEPRO will also have a shortened time frame, which will be noted on the inquiry letter.
  • Medicare beneficiaries, or their representatives, will have the opportunity to request a second review if they disagree with the original findings, similar to the current process in place for providers.
The official effective date for the quality of care review changes is unknown at this time. KEPRO will post updated information in regard to the effective date when provided by CMS.
CMS and the American Medical Association (AMA) have come to agreement regarding the implementation of ICD-10, which clears the way for ICD-10 to be effective on October 1, 2015. Physicians will get a "safe harbor" for Part B processing for one year, but Part A provider's coding and reimbursement will be according to ICD-10. For additional guidance regarding the implementation of ICD-10, click here. 

 Medicare - Happy 50th Anniversary!

Medicare and Medicaid: Keeping Us Healthy for 50 Years
It's easy to forget that before 1966, roughly half of all seniors were uninsured, living in fear that the high cost of health care could propel not only them, but their families, into poverty. Few of us remember that not that long ago, far too many disabled people, families with children, pregnant women and low-income working Americans were unable to afford the medical care they needed to stay healthy and productive. More
Publication No. A234-193-8/2015. 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.