Fall
2015
ISSUE
No. 4
CASE REVIEW CONNECTIONS
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Medical Director's Corner - Ferdinand Richards III, MD
One of the roles of the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) is to review quality of care concerns. These concerns may come from a beneficiary complaint, but they also may come up during other types of reviews, such as appeals or Higher-Weighted Diagnosis-Related Group (HWDRG) reviews. When a potential quality of care concern is identified, the provider or practitioner will be given an opportunity to respond before a concern is confirmed. Please know that the quality review is done in a spirit of collegiality and quality improvement and is not meant to be punitive. KEPRO does not typically report this type of information to other oversight agencies, and our work product is covered under federal confidentiality regulations.
  
Because there is the possibility that one day you or your facility may receive this type of correspondence from the BFCC-QIO, I wanted to share some tips that will assist providers and practitioners with their response to this type of correspondence.
  
1. KEPRO sends correspondence to the address for your organization that is listed in the Medicare database. If you are aware that mail has not been sent to the correct address, please let us know, so that we may resend it.
  
2. Time frames must be adhered to. These time frames are provided by the Centers for Medicare & Medicaid Services (CMS), and as a CMS contractor, we must enforce them.
  
3. Please respond to the questions as specifically as possible with the necessary clinical information, as this response will be provided to the Physician Reviewer, who will then make the determination if the concern will be resolved or confirmed.
  
4. You will be notified by the BFCC-QIO if the concern is confirmed or resolved. Cases with confirmed concerns may be addressed by either the BFCC-QIO or the Quality Innovation Network QIO (QIN-QIO) with a corrective action plan, based on the severity of the concern.
  
5. Please take the correspondence seriously and respond in a timely manner.
Hospital-Issued Notice of Non-coverage (HINN) Information
Hospitals provide Hospital-Issued Notices of Non-coverage (HINNs) to beneficiaries prior to admission, at admission, or at any point during an inpatient stay if the hospital determines that the care the beneficiary is receiving, or is about to receive, is not covered by Medicare because it is:
  • Not medically necessary;
  • Not delivered in the most appropriate setting; or
  • Is custodial in nature.

Fee-For-Service (FFS) HINNs

  • HINN 10, also known as the Notice of Hospital Requested Review (HRR), should be issued by hospitals to beneficiaries in Original Medicare whenever a hospital requests QIO review of a discharge decision without physician concurrence.
  • HINN 11, which is used for non-covered items or services provided during an otherwise covered stay, and its instructions have not yet been incorporated into Chapter 30 of the Online Claims Processing Manual.
  • HINN 12 should be used in association with the Hospital Discharge Appeal Notices to inform beneficiaries of their potential liability for a non-covered continued stay.
  • The Preadmission/Admission HINN, used prior to an entirely non-covered stay, is also known as HINN 1 and replaces HINNs 1 and 9.

Preadmission: In preadmission situations, the beneficiary is liable, if admitted, for customary charges for all services furnished during the stay, except for those services for which he or she is eligible to receive payment under Medicare Part B.

 
Admission: If the admission notice is issued at 3 p.m. or earlier on the day of admission, the beneficiary is liable for customary charges for all services furnished after receipt of the notice, except for those services for which the beneficiary is eligible to receive payment under Medicare Part B.
 
If the admission notice is issued after 3 p.m. on the day of admission, the beneficiary is liable for customary charges for all services furnished on the day following the day of receipt of the notice, except for those services for which the beneficiary is eligible to receive payment under Medicare Part B. 
 
This information regarding liability should be furnished on the HINN. HINNs (and instructions) may be found at https://www.cms.gov/bni.

Hospital Immediate Advocacy Success Story

A beneficiary's wife contacted the BFCC-QIO with concerns about her husband's care in the hospital. He was in the hospital for the second time in six weeks after a lung cancer diagnosis and was supposed to be getting physical therapy and treatments. That was not occurring, and the pulmonary doctor had not been in to speak with them. She felt overwhelmed because she did not understand what was going on. She attempted to speak with the nursing supervisor but did not get the answers she needed. She contacted the hospital administration, but no one answered the phone. She did not know who the Patient Advocate or Case Manager was. To assist the wife, KEPRO's Intake Specialist agreed to make a call to the Case Manager or the Patient Advocate for an update on her husband's plan of care.
 
The Intake Specialist received calls from both the Director of Case Management and the Unit Director for the patient. They agreed to assess and evaluate the beneficiary's dietary needs, to discuss the issues regarding the therapy session with the Therapy Director, and to put calls in to the doctor to set up a meeting time with the family. The Intake Specialist then contacted the beneficiary's wife to let her know what had taken place and to let her know that someone from the hospital would be following up with her.

 Technical Denials

KEPRO would like to make providers and practitioners aware of the new policy related to technical denials. In the past, many providers and practitioners were not subject to technical denials. That policy has now been changed to include all providers and practitioners.
 
Pursuant to 42 C.F.R. Part 476.90, as amended on August 31, 2012, at 77 Fed. Reg. 53,258, 53,664-665, 53,682-683, the BFCC-QIO's authority to issue technical denials now applies to providers or practitioners of any kind, regardless of setting, when they do not submit the medical records requested. The regulations also indicate that those providers and practitioners that refuse to allow a BFCC-QIO "to enter and perform the duties and functions required under its contract with CMS" may also be subject to a technical denial. Therefore, a BFCC-QIO may impose a technical denial where providers and practitioners do not comply with the requirements for case review as opposed to simply failing to submit medical records. BFCC-QIOs are therefore directed to issue technical denials when providers or practitioners in any setting fail to submit medical records when requested or refuse to permit the BFCC-QIO to enter and perform BFCC-QIO duties in the course of a medical review.

 Coding Updates

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ICD-10 is now here! For provider HWDRG reviews, KEPRO will process according to the code version billed by the provider on the specific HWDRG claim. Claims billed as ICD-9 will be reviewed in accordance with the ICD-9-CM Official Guidelines for Coding and Reporting. Claims billed as ICD-10 will be reviewed in accordance with the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting.

 Two-Midnight Short-Stay Reviews

CMS announced changes to its approach with regard to educating providers and enforcing Two-Midnight Short-Stay Reviews. Specifically, CMS has decided to use BFCC-QIOs, rather than Medicare Administrative Contractors (MACs) or Recovery Auditors, to conduct the first line medical reviews of providers who submit claims for inpatient admissions. BFCC-QIOs have a significant history of collaborating with hospitals and other stakeholders to ensure high quality care for beneficiaries.
 
BFCC-QIO Two-Midnight Short-Stay Reviews will focus on educating doctors and hospitals about the Part A payment policy for inpatient admissions. Recovery Auditor Patient Status reviews will be conducted by the Recovery Auditors for those hospitals that have consistently high denial rates based on Two-Midnight Short-Stay Review outcomes.
 
More details about the proposed changes can be found on KEPRO's website including a recorded webinar on the Two-Midnight Rule. KEPRO would like to encourage providers to submit the Contact Update form for the Two-Midnight Short-Stay reviews, which can be found here.
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: January 21, 2016, 2:00 p.m. - 3:00 p.m. ET
Speakers: Tara Cooke, Outreach Specialist, KEPRO; Sylvia Gaddis, Outreach Specialist, KEPRO
 
FAQs
  
Q. What if the beneficiary did not fully read their discharge notice and has already been discharged from the facility? What options would there be? Is Immediate Advocacy the only option, or is there any way to do an appeal after they have already left the facility?
 
A. If a beneficiary felt that the discharge was not appropriate, he/she could file a quality of care complaint about a premature discharge. Beneficiaries cannot appeal after they have left the facility.
 
Q. If a gross and flagrant violation is found and the case goes through the sanction process, is the beneficiary or representative notified?
 
A. At the direction of CMS, the beneficiary and/or representative will be told that due to the serious nature of their concern, the BFCC-QIO is taking appropriate action. They are not told about the sanction process or what actions may come from this process.
 
 
KEPRO
Publication No. A234-226-11/2015. 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.