No. 3

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 to learn more about topics that interest you.
Medical Director's Corner
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.

Post-Acute FAQs

Q. Does the Notice of Medicare Non-coverage (NOMNC) need to be given in paper form to the beneficiary? Some providers, in an effort to become paperless, are showing the notices to the beneficiary on a tablet and not giving the beneficiary a paper copy. In addition, some providers are trying to push paperwork to online patient portals. Would attaching the notice to a patient portal satisfy the requirement?
A. The patient must be given a copy of the notice. For more information, go to MLN Matters.
Q. What is the time frame that information has to be given to KEPRO once they receive a fax that the appeals process has been started?
A. For skilled services appeals, the information must be received by close of business (COB) on the day the information has been requested.
Q. Does the online case status check not show information about second level appeals? 
A. There is a reconsideration tab that shows a second level appeal has been requested. Not all second level appeals are completed by KEPRO.

Skilled Nursing (SNF) 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 a home health agency. The agency staff came out one time to insert an indwelling catheter, but the agency had not discharged him from care. Because of this, he was not able to get his wound care supplies from another supplier. He had made numerous calls to the home health agency and was not able to get either the supplies or a discharge. He requested intervention by the Intake Specialist at the BFCC-QIO.
The Intake Specialist contacted the home health agency and spoke with the Director of Nursing (DON). The DON stated that there must be a billing issue that is stopping the discharge. She agreed to address that, so that the beneficiary's supplies could be provided by either the wound care center or another durable medical equipment supplier. The Intake Specialist then contacted the beneficiary and explained that the DON felt that there was an issue that was stopping the discharge and that the DON would be addressing that issue. She also stated that the DON would be following up with the beneficiary, to make sure that the situation had been taken care of.

Expedited Determinations

What is an untimely Medicare Advantage (MA) case (post-acute)?
When a beneficiary or his/her representative has been issued a valid notice and the call to request an appeal is received after 12 noon on the day prior to the effective date.
How would this be processed?
After the NOMNC has been determined to be valid, the beneficiary or his/her representative is called and informed that since the call to the BFCC-QIO was after the deadline, appeal rights are now through the managed care plan, and he/she should call the number on the health plan card. The managed care plan and the facility are also called and informed that the beneficiary or the representative have been referred to the managed care plan.
What is an untimely BIPA case (post-acute)?
When a beneficiary or his/her representative has been issued a valid notice and the call to request an appeal has missed the deadline of noon the day prior to the effective date.
How would this be processed?
The case is reviewed, but it is NOT expedited. If the patient is still receiving services, the case must be completed within 7 days of the request call; if the patient is NOT receiving services, the case must be completed within 30 days of the request call. More
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.
MEDICARE'S 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. A234-194-8/2015. 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 Serivces. The contents presented do not necessarily reflect CMS policy.