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Medical Director's Corner - Ferdinand Richards III, MD
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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 (DRGs). 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.
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Detailed Explanation of Non-coverage
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Home health agencies, skilled nursing facilities, hospices, and comprehensive outpatient rehabilitation  facilities are required to provide a Notice of Medicare Non-Coverage (NOMNC) to beneficiaries when their Medicare covered service(s) are ending. The NOMNC informs beneficiaries how to request an expedited determination from their BFCC-QIO.
A Detailed Explanation of Non-Coverage (DENC) is given only if a beneficiary requests an expedited determination. The DENC explains the specific reasons for the end of services.
The following information should be provided on the DENC, using full sentences and in plain English:
- Patient specific information that describes the current functioning and progress of the beneficiary/enrollee with respect to the services being provided.
- Specific reasons why services are either no longer reasonable or necessary for the beneficiary/enrollee or are no longer covered according to the Medicare guidelines. Describe how the beneficiary/enrollee does not meet these guidelines.
- The reasons services are no longer covered according to the plan's policy guidelines, if applicable. Describe how the enrollee does not meet these guidelines. If the plan relied exclusively on Medicare coverage guidelines, please explain.
- If the plan has not provided the Medicare guidelines or policy used to decide the termination date, inform the beneficiary/enrollee how and where to obtain the policy. Provide a telephone number for beneficiary/enrollee to get a copy of the relevant documents sent to KEPRO.
For more information, please visit BNI.
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SNF 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 beneficiary contacted KEPRO with concerns about her home health services. She was supposed to be receiving wound care once a week and did not feel that the agency staff was following the physician's orders. When she saw her doctor, he expressed concern about the way the wound was being packed. The BFCC-QIO Intake Specialist agreed to contact the agency on her behalf regarding her concerns.
The Intake Specialist contacted the Administrator at the home health agency. The Administrator explained that the beneficiary was having a lot of anxiety regarding her condition and was continually calling the Case Manager. The Administrator listed out all the visits that the beneficiary had received and confirmed that they had followed the physician's orders. Regarding the physician's concerns about the wound packing, there were no calls from the physician regarding additional training for the wound packing. The physician did speak with the agency about the beneficiary's nutrition and having her change positions during the night, to keep pressure off of the wound. He also recommended less packing because the wound was healing. The Administrator agreed to have the Case Manager call the beneficiary and provide the physician's recommendations. The Intake Specialist followed up with the beneficiary to let her know that the Case Manager would be contacting her about any future concerns.
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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.
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Q. What is the proper process to inform the BFCC-QIO that a patient has transferred to a higher level of care (such as from a SNF to an acute care hospital) when an appeal has been placed?
A. Please send the BFCC-QIO written notification that the patient has been moved to a higher level of care and is no longer at your facility. No appeal will be required under these circumstances.
Q. Is the Notice of Medicare Non-coverage (NOMNC) the same as the Advance Beneficiary Notice (ABN)?
A. There is a difference between the two. The NOMNC is used in the post-acute setting for termination of service appeals. The ABN is used with outpatients in multiple settings. KEPRO does not do the appeal for the ABN.
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Memorandum of Agreement (MOA)
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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.
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Beneficiary Notices Initiative (BNI) Website
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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:
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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.
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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
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