SUMMER
2016
ISSUE
No. 7

CASE REVIEW CONNECTIONS
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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.
Hospital Discharge Appeals
Hospitals are required to deliver the Important Message from Medicare (IM) to all Medicare beneficiaries who are hospital inpatients. The IM informs inpatient beneficiaries of their hospital discharge appeal rights.
Medicare beneficiaries who are admitted in the hospital initially as inpatient and a day or two later have their status changed to observation do not have appeal rights through the BFCC-QIO. Observation appeals may be processed through the Medicare Administrative Contractor (MAC).

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 a verbal complaint. Below is an example of a KEPRO Success Story.
A Medicare beneficiary's wife contacted the BFCC-QIO with concerns about her husband's care in the hospital. He was admitted to the hospital with bleeding from the nose and mouth. They packed his nose and scheduled him for surgery to cauterize the bleeding. She stated that the physician had not seen her husband in 48 hours, and he was scheduled for surgery the day before. He was kept NPO (nothing by mouth), but the surgery was not done, and the bleeding was continuing. Her husband had a managed care plan, and the hospital copay was 20% per day. The wife was concerned that her husband was in the hospital, but nothing was being done. She requested advocacy, so that she could receive some answers for her concerns.
The KEPRO Intake Specialist contacted the Director of Care Coordination at the hospital. She was unaware of the wife's concerns. She agreed to check on the physician's status and determine if he had made his rounds that morning. She also stated that she would be following up with the beneficiary and his wife, to address their concerns, and would check on the NPO status and would make sure that the staff is responding as needed.
The KEPRO Intake Specialist then contacted the beneficiary's wife and explained that the Director of Care Coordination would be following up with her. The beneficiary's wife was very appreciative of the advocacy efforts.

 Medicare Outpatient Observation Notice (MOON)

The MOON is available for comment as of August 2016, which will last 30 days. CMS will provide additional information related to MOON implementation on its Beneficiary Notices Initiative (BNI) webpage when the MOON is approved. The BFCC-QIO will not have review authority for these notices.

Higher Weighted Diagnosis-Related Group (HWDRG) Reviews

KEPRO has completed approximately 40,500 HWDRG reviews for the contract-to-date period of August 31, 2014, through April 30, 2016.  We will be sharing data on a profile basis with providers. 
The states with the highest volume of provider requested HWDRG reviews are listed below, with the combined reviews of Florida and Texas representing approximately 41% of reviews completed.

The Top 10 most frequently requested DRGs for review are identified below:
DRG Code
Definition
871
Septicemia or severe sepsis
291
Congestive heart failure w/mcc
682
Renal failure w/mcc
193
Simple Pneumonia w/mcc
190
Chronic obstructive pulmonary disease
177
Bacterial Pneumonia w/mcc
683
Renal failure w/cc
378
GI Hemorrhage w/cc
189
Respiratory failure
853
Infectious and parasitic diseases w/OR procedure w/mcc
The Top 10 DRGs (11 are listed because the last three codes have the same number of reviews) that resulted in the highest number of claim adjustments to the DRG are as follows:
DRG Code
Definition
871
Septicemia or severe sepsis
682
Renal failure w/mcc
177
Bacterial Pneumonia w/mcc
291
Congestive heart failure w/mcc
853
Infectious and parasitic diseases w/OR procedure w/mcc
193
Simple Pneumonia w/ mcc
308
Cardiac Arrhythmia & Conduction Disorders w/mcc
292
Heart Failure and Shock w/cc
689
Urinary Tract Infection w/mcc
870
Septicemia or severe sepsis w/ MV 96+ hours
683
Renal failure w/cc
We look forward to collaborative and educational sessions with our providers as we further research case mix and DRG coding patterns and profiles.
FAQs - Hospital
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 the appeal process differ for a hospital swing bed from the hospital discharge appeal process?
A. Yes. The swing bed is not considered acute care. A Notice of Medicare Non-Coverage would need to be issued instead of the Important Message from Medicare.
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. A234-339-8/2016. 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 Services. The contents presented do not necessarily reflect CMS policy.