No. 6

Medical Director's Corner - Ferdinand Richards III, MD
One of the functions of the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) is to conduct quality of care reviews. These reviews can come from beneficiary complaints, referrals from other subcontractors, or other BFCC-QIO reviews, such as Higher-Weighted Diagnosis Related Groups (HWDRG). Once the review is sent out to the Peer Reviewer, if it comes back with either a Gross & Flagrant determination or a Substantial Number of Substantial Violations determination, that case could become eligible to be referred for Sanction to the Office of the Inspector General (OIG). Once this occurs, the review takes a different path than a normal quality of care review. In this column, I would like to share some of the process that occurs if you or your facility receives correspondence related to a potential Sanction. Please know that this process is meant to be collegial and to improve the quality of care and is not meant to be punitive.
Once the possible Sanction determination comes back from the Peer Reviewer, it is sent to two other Peer Reviewers. If two out of three concur regarding the possible Sanction determination, the provider is notified of the findings and is provided with the opportunity to respond in writing or to have a face-to-face meeting with KEPRO. If the provider requests a face-to-face meeting, staff members from KEPRO will travel to meet with the provider along with the Sanction panel. The Sanction panel is comprised of physicians that will assist KEPRO in making a determination whether the case truly is a possible Sanction case.
If the concerns are determined not to be Gross & Flagrant or Substantial Number of Substantial Violations after the written explanation or the meeting, then the case will revert to a normal quality of care review. If the concerns are determined to be confirmed as Gross & Flagrant or Substantial Number of Substantial Violations, the provider/practitioner will be required to submit a Corrective Action Plan (CAP). This may include submitting data to KEPRO over a required time period, such as a year. Once the CAP has been completed to the satisfaction of KEPRO, the case will be complete. If the CAP is not completed appropriately, the case may be recommended for Sanction to the OIG. For more information about the Sanction process, please visit www.cms.gov.
Hospital Discharge Appeals
Hospitals are required to deliver the Important Message from Medicare (IM), CMS-R-193 to all Medicare beneficiaries (Original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospital inpatients. The IM informs hospitalized inpatient beneficiaries of their hospital discharge appeal rights.
Beneficiaries who choose to appeal a discharge decision must receive the Detailed Notice of Discharge (DND) from the hospital or their Medicare Advantage plan, if applicable.
The following information is to be provided on the DND, using full sentences and in plain English:
  • Check the applicable Medicare and/or managed care policies. If necessary, hospitals may also use the selection "Other" to list other applicable policies, guidelines, or instructions. Hospitals or plans may also preprint frequently used coverage policies or add more space below this line, if necessary. In addition, the hospital or plan may attach additional pages, specific policies, or discharge criteria to the notice. Any attachments must be included with the copy sent to KEPRO as well.
  • Fill in detailed and specific information about the patient's current medical condition and the reasons why services are no longer reasonable or necessary for this patient or are no longer covered according to Medicare or Medicare managed care coverage guidelines.
  • The hospital/plan should also supply a telephone number for patients to call to get a copy of the relevant documents sent to the BFCC-QIO. If the hospital/plan has not attached the Medicare policies and/or the Medicare managed care plan policies used to decide the discharge date, the hospital should supply a telephone number for patients to call to obtain copies of this information.
Further information is available at BNI.

Hospital Immediate Advocacy Success Story

Immediate Advocacy is an informal process in which the BFCC-QIO acts as a liaison for the Medicare beneficiary to quickly resolve an oral complaint. Below is an example of a KEPRO Success Story.
A Medicare beneficiary contacted KEPRO with concerns about the patient care that she received at the hospital. She had bypass surgery at the hospital and felt that the staff was short with her and not responsive to her needs. She had many hoses and wires on her, and that caused a lot of discomfort along with the pain from the procedure.
The BFCC-QIO Intake Specialist contacted Patient Relations at the hospital. The Patient Relations representative spoke to the beneficiary and listened to her concerns. She stated that the beneficiary was satisfied after their conversation, and the concerns were provided to the nursing manager.
The Intake Specialist followed up with the beneficiary. She expressed her appreciation for the opportunity to express her feelings and thanked the Intake Specialist for her time.

 PHI Security Incidents

Recently, KEPRO has received protected health information (PHI) from various providers that was not related to KEPRO's services or attributable to a current KEPRO review/appeal case. This is considered an external security incident, which violates HIPAA regulations.
Under our contractual guidelines, KEPRO is required to report incidents of this type to QualityNet, a subcontractor for the Centers for Medicare & Medicaid Services (CMS), for tracking purposes. Providers should follow their internal processes regarding HIPAA compliance. If your facility sent unsolicited medical records to KEPRO, a member of our staff would have reached out to the designated QIO Liaison or Appeals contact person and notified that individual of the potential breech. By alerting all providers of this concern, we hope that they will look at their own internal processes, to assist KEPRO with resolving this concern.  

Click here for more information about HIPAA security incidents, provided by the HIPAA Survival Guide. If the link doesn't work, go to HIPAA Survival Guide at hipaasurvivalguide.com/hipaa-regulations/164-304.php. If you have questions or need additional information, please contact Cheryl A. Cook, RN at 813-280-8256, ext. 7201 or Cheryl.Cook@bfcc2.hcqis.org.  
FAQs - Hospital
Q. In the case of hospital appeals, since there's no financial liability while the case is being reviewed, what will the patient have to pay for?
A. Assuming that the Medicare beneficiary has made a timely request (before midnight on the day of discharge), the patient will still be responsible for any copays or deductibles associated with the hospital stay. However, during the appeal, the patient is completely financially protected until KEPRO makes its determination.
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.

 Memorandum of Agreement (MOA)

KEPRO is the BFCC-QIO authorized by the Medicare program to review medical services provided to Medicare beneficiaries in CMS Areas 2, 3, and 4. As you may know, KEPRO reviews medical records to determine whether services delivered to these beneficiaries meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. We also review hospital discharge appeals and termination of services appeals for Medicare beneficiaries.

In order to participate in the Medicare program, certain providers are required under federal law to have a Memorandum of Agreement (MOA) with a BFCC-QIO. MOAs outline the BFCC-QIO's and provider's responsibilities during the review process.

Section 1866 (a)(1)(E) of the Social Security Act requires providers of services to have an agreement with BFCC-QIOs to release data related to patients when a BFCC-QIO requests it.

Section 1866 (a)(1)(F)(i) of the Social Security Act requires hospitals which provide inpatient hospital services paid under the Prospective Payment System (PPS) to maintain an agreement with BFCC-QIOs to review the validity of diagnostic information provided by such hospitals, the completeness, adequacy and quality of care provided, the appropriateness of admissions and discharges, and the appropriateness of care provided for which additional payments are sought.

Section 1866 (a)(1)(F)(ii) of the Social Security Act requires hospitals, critical access hospitals (CAHs), skilled nursing facilities (SNFs), hospices, long-term acute care facilities (LTACs),
comprehensive outpatient rehabilitation facilities (CORFs)
, and home health agencies (HHAs) to maintain an agreement with a BFCC-QIO to perform certain functions.

The MOA describes (a) KEPRO procedures with respect to certain contract obligations and (b) review and appeal rights providers have with respect to these obligations. For more information, go to
MOAs on KEPRO's website.
Beneficiary Notices Initiative (BNI) Website
The URL for the BNI website has recently changed. This is the website where important information about discharge appeals and service terminations can be found, including downloads of all the CMS forms. Some of the forms are also available in Spanish. The new website can be found at:

KEPRO has created a tiny URL for your convenience: http://tiny.cc/BNI

 HWDRG Reviews

As part of our HWDRG reviews, KPERO receives many cases which fall under the "72 Hour Rule," also known as the "three-day payment window." In these cases, the claim for an outpatient procedure is often combined with the inpatient claim, resulting in a claim resubmission that becomes a HWDRG case. Therefore, KEPRO needs the inpatient medical record and the outpatient record that was combined with the claim to facilitate our review of the claim. Inclusion of both record components with the provider's initial submission enables us to more efficiently adjudicate our review of HWDRG cases that arise as a result of the three-day payment window.
Please note our new phone extensions:
Two-Midnight Short-Stay review: ext. 7480
HWDRG:  ext. 7475

Contact Information
If you need to update your organization's contact information with KEPRO, you can find the available forms on our website, www.keproqio.com.

General Provider Update Form - for MOAs, QIO Liaison changes, and general updates

Appeals Contact Form - designate the staff in your facility that needs to be contacted for appeals

Two-Midnight Contact Form - designate the staff in your facility that needs to be contacted related to the Two-Midnight Short-Stay reviews
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:  May 31, 2016, 2 p.m. - 3 p.m. ET
Speakers:  Brittny Bratcher, Outreach Specialist, KEPRO; Nicole Zager, Outreach Specialist, KEPRO
2015 QIO Program Progress Report
Publication No. A234-330-5/2016. 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.