SUMMER
2016
ISSUE
No. 7

CASE REVIEW
CONNECTIONS  
          
Medical Director's Corner - Ferdinand Richards III, MD
Recently, the Centers for Medicare & Medicaid Services (CMS) put out its annual Quality Improvement Organization (QIO) Program Progress Report, which provides updates on the activities of the QIO Program. In this report are the accomplishments of both the Beneficiary and Family Centered Care QIOs (BFCC-QIOs) and the Quality Innovation Network QIOs (QIN-QIOs).
 
During 2015, the BFCC-QIOs completed 172,482 reviews and saved the Medicare program $9.4 million processing Higher Weighted Diagnosis-Related Group (HWDRG) reviews. More than 135,000 discharge appeal reviews were completed, resulting in 27,000 beneficiaries not being discharged when they needed continued care. Appeal types include skilled nursing facilities, acute rehabilitation, hospital, and hospice discharges as well as admission denials. The report also shares several Immediate Advocacy success stories, where beneficiaries had concerns resolved with the assistance of BFCC-QIO. KEPRO also performs beneficiary complaints, general quality of care reviews, and EMTALA reviews.
 
The QIN-QIOs also had a banner year, as they exceeded recruitment targets for six initiatives. QIO Program representatives, along with other CMS and Department of Health and Human Services (HHS) members of the National Hospital-Acquired Condition and Readmission Reduction Team, received HHS' highest award, the Secretary's Award for Distinguished Service, for the team's work in reducing patient harm and readmissions in hospitals nationwide.

Learn more about the impact of the QIO Program in your state.
Post-Acute Appeals
Beneficiaries have a right to an appeal when they are receiving skilled services, and the services are to end. Per Medicare guidelines, if a beneficiary is receiving multiple skilled services at one time, there should not be a Notice of Medicare Non-Coverage issued until it is determined that the last skilled service should end. For example, a beneficiary is receiving physical therapy (PT), occupational therapy (OT), and skilled nursing, and PT/OT states that the beneficiary has met his/her short term goals, and therapy should end. However, skilled nursing needs to continue, due to wound care needs or antibiotic therapy. There would not be a Notice of Medicare Non-Coverage given until it is determined that the skilled nursing should end. Then the beneficiary may file an appeal.
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 the BFCC-QIO with concerns about her wound care. She was receiving wound care services from a home health agency during the week but was not receiving care on the weekend even though it was ordered by the doctor. Therefore, the beneficiary called KEPRO for assistance.
 
The KEPRO Intake Specialist held a conference call with the home health agency and the beneficiary. The manager at the home health agency researched the issue and determined that there was a scheduling issue regarding the weekend services. She apologized to the beneficiary for the mistake and noted that she was appropriately scheduled for the next weekend. The beneficiary thanked the Intake Specialist for her efforts and felt that the matter was resolved.

Post-Acute FAQs

Q. Is it standard practice for the BFCC-QIO to contact the facility to verify dates of services prior to sending the medical record request?
 
A. It is standard practice to verify dates of service before sending the medical record request. The beneficiary does not always provide the correct dates, and it can delay the review to have to send a second request if the first one is not correct.
 
Q. Does a 3-day stay in inpatient hospice count towards skilled facility care?
 
A. No. It must be a hospital stay.
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:  September 22, 2016, 2 p.m. - 3 p.m. ET
Speakers: Sylvia Gaddis, Outreach Specialist, KEPRO; Nancy Jobe, Outreach Specialist, KEPRO
 
    
  
      
Publication No. A234-338-8/2016. 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 Serivces. The contents presented do not necessarily reflect CMS policy.