FALL
2015
ISSUE
No. 4
CASE REVIEW
CONNECTIONS  
          
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 Diagnostic-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.
Annotating the Notice of Medicare Non-coverage (NOMNC)
As noted in MLN MM7903:
If the beneficiary refuses to sign the Notice of Medicare Non-coverage (NONMC), staff should annotate the notice to that effect and indicate the date of refusal on the notice. The date of refusal is considered to be the date of notice receipt. Please note that beneficiaries who refuse to sign the NOMNC still remain entitled to an expedited determination.
 
Regarding the issuance of the NOMNC via telephone:

 

Staff should inform the representative of the beneficiary's right to appeal a coverage termination decision and include the following information:

  • The beneficiary's last day of covered services and the date when the beneficiary's liability is expected to begin;
  • The beneficiary's right to appeal a coverage termination decision;
  • A description of how to request an appeal by a BFCC-QIO;
  • The deadline to request a review as well as what to do if the deadline is missed; and
  • The telephone number of the BFCC-QIO to request the appeal.
If staff chooses to contact the representative by telephone, the date the information is communicated is considered the NOMNC's receipt date. Staff should annotate the NOMNC to document the telephone contact with the representative on the day that the telephone call is made, reflecting that all of the information indicated above was included in the communication. The annotated NOMNC should also include the name of the staff person initiating the contact, the name of the representative contacted by phone, the date and time of the telephone call, and the telephone number called. Staff must place a dated copy of the annotated NOMNC in the beneficiary's medical file and mail a NOMNC to the representative on the day the telephone contact is made.
Immediate Advocacy Success Story
A beneficiary contacted the BFCC-QIO with concerns about her care at a skilled nursing facility. She had breast cancer and diabetes, and her surgical wounds were not healing. She was transferred from the hospital to the skilled nursing facility for wound care. She was concerned that on the night she was admitted, they lost the wound vac and her medications, and she went over 12 hours without them. When they found the wound vac, the staff did not follow the doctor's orders regarding the dressings. She was also having some issues with the staff, and therefore, she requested a transfer to another facility.
 
The Intake Specialist contacted the Social Worker at the facility and received a call back. The Social Worker explained that the motor on the wound vac had burned out upon the beneficiary's arrival, and it had to be replaced, which was the reason for the delay. However, staff also agreed that a transfer might be best since there were ongoing issues. The Director of Social Work was in the process of sending out referrals to locate another bed at another facility.
   
The Intake Specialist contacted the beneficiary and explained that she was scheduled for wound care assessment with the wound care nurse and the facility physician that afternoon. The Intake Specialist also explained that staff was working to get her transferred to another facility or home with home health, based on the level of care appropriate for her medical needs.
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 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 QIO duties in the course of a medical review.
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
 
Post-Acute 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, they could file a quality of care complaint about a premature discharge. They 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. A234-227-11/2015. 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 Serivces. The contents presented do not necessarily reflect CMS policy.