Case Review Connections
Acute Care Edition
Issue 22: Fall 2020
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In this issue:
One of the highest volume reviews that Kepro performs is appeals. This includes hospital discharge and skilled service termination appeals, which affect a variety of providers, including hospitals, acute rehabilitation facilities, long-term acute care hospitals, critical access hospitals, skilled nursing facilities, home health agencies, hospices, and outpatient rehabilitation facilities. Medicare beneficiaries are given the Important Message from Medicare (IM) in acute care facilities, and they can call Kepro and request that their services continue.
Many providers have questions about the criteria that Kepro uses to make these decisions. When reviewing cases, Kepro strives to use Physician Reviewers from the same state in which the beneficiary is receiving medical care. These physicians have been trained by Kepro on Medicare's guidelines related to continuing care. They also use their professional judgement regarding the safety of a discharge. Some examples of what the physician would look for in a hospital review include medical stability and a safe discharge plan. Some examples of what a physician would look for in a skilled nursing review when the patient is getting physical therapy include whether the patient has met his/her goals, current functional capacity, and a safe disposition.
Kepro has several states with a high appeal review denial (by percentage), meaning that Kepro agrees with the patient. Historically, denials are made due to the lack of medical record documentation to support the decision to discontinue skilled services. If the chart is incomplete or the documentation is poor and the physician cannot determine whether the patient can be safely discharged, he/she will always find in favor of the patient. The submitted medical record needs an appropriate level of detail as well as consistency. (An example of inconsistency would be where the physician states that the patient is walking 150 feet with minimal help, yet the physical therapy notes state the patient is walking 25 feet with maximum support). Decisions by the Physician Reviewers are also reviewed by one of Kepro's three Medical Directors, to make sure that guidelines are being followed. More information about the volume of reviews and the rate in which appeals are overturned is available in Kepro's Annual Reports.
When a Medicare beneficiary is not competent to receive the Important Message from Medicare, the facility will need to provide the notice to his/her representative. If the hospital is unable to deliver a notice to a representative in person, then the hospital staff should telephone the representative to advise him or her of the right to appeal a discharge decision.
The information provided should include the following at a minimum:
- the name and telephone number of a contact at the hospital;
- the beneficiary’s planned discharge date and the date when the beneficiary’s liability begins;
- the beneficiary’s rights as a hospital patient, including the right to appeal a discharge decision;
- how to get a copy of a detailed notice describing why the hospital and physician believe the beneficiary is ready to be discharged;
- a description of the steps for filing an appeal;
- when (by what time/date) the appeal must be filed to take advantage of the liability protections;
- the BFCC-QIO, including any applicable name, address, telephone number, fax number or other method of communication the BFCC-QIO requires in order to receive the appeal in a timely fashion;
- direction to the 1-800-MEDICARE number for additional assistance to the representative in further explaining and filing the appeal; and
- the date the hospital conveys this information to the representative, whether in writing or by telephone, is the date of receipt of the notice.
Confirm the telephone contact by mailing the written notice on that same date. Place a dated copy of the notice in the beneficiary’s medical file and document the telephone contact with the beneficiary’s representative (as listed above) on either the notice itself or in a separate entry in the beneficiary’s file or attachment to the notice. The documentation should indicate that the staff person told the representative
- the planned discharge date,
- the date the beneficiary’s financial liability begins,
- the beneficiary’s appeal rights, and
- how and when to initiate an appeal.
The documentation 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 contact, and the telephone number called.
For more information, please see the Centers for Medicare & Medicaid Services (CMS) Manual: Pub 100-04 Medicare Claims Processing (PDF).
Visit Kepro's COVID-19 resource page to keep up with the latest news from CMS for healthcare providers.
Immediate Advocacy is an informal process in which the BFCC-QIO acts as a liaison for people with Medicare to quickly resolve an oral complaint. Kepro would like to share success stories with providers to show how Immediate Advocacy can benefit providers by resolving problems quickly, which leads to improved patient relations.
A Medicare beneficiary’s wife contacted Kepro with concerns about her husband’s pain management at the long-term acute care facility. He was getting his pain medication by mouth even though he was NPO (nothing by mouth). The day before she called, he did not receive his pain medication at all. He was scared to speak up and just felt that his care was poor in general. His wife wanted assistance from Kepro to get him transferred to another facility.
The Clinical Care Coordinator (CCC) at Kepro called the case manager at the facility and detailed the wife’s concerns by voicemail. The CCC then received a return call from the case management director stating that she had spoken with the beneficiary, his wife, and nursing leadership. She stated that the facility staff were taking the beneficiary’s concerns seriously, and that it was agreed by all that he would continue to stay at the facility. The CCC then contacted the wife who stated that she appreciated the assistance from Kepro.
|Q.||Where can I find the instructions to fill out the IM?|
|A.||Instructions can be found at the CMS Beneficiary Notices website under Hospital Discharge Appeal Notices.|
|Q.||Is there a Spanish version of the notice?|
|A.||Yes. It can also be found at the CMS Beneficiary Notices website under Hospital Discharge Appeal Notices.|
The Beneficiary Care Management Program (BCMP) is a Person and Family Engagement initiative from CMS. It serves as an enhancement to the appeals process for BFCC-QIOs. The purpose of the BCMP is to address care management issues for Medicare Fee-for-Service (FFS) beneficiaries with complex healthcare needs and limited knowledge of available resources.
Family members and/or caregivers may be referred to the program by the BFCC-QIOs at any time during the review of a hospital discharge or skilled service termination appeal. BCMP assistance is offered at no cost to beneficiaries, family members, and caregivers. The BCMP works collaboratively with healthcare providers in supporting the beneficiary and his/her family or caregiver with assistance reviewing discharge instructions and post-treatment plans; helping to coordinate follow-up care; and assisting with referrals to community resources or person and family engagement (PFE) partners.
If a Medicare beneficiary has an active hospital discharge or skilled service termination appeal, contact Kepro to discuss if he/she could benefit from this service.
One of the roles of Kepro Outreach staff is to build relationships and collaborate with other organizations that work with the senior (+65) population. The State Health Insurance Assistance Programs (SHIP) are found in every state and most territories of the United States. They are valuable partners in our mission of providing information to seniors about Kepro’s services.
Funded by the United States government, SHIPs counsel Medicare patients and their families about Medicare. SHIPs are staffed by paid professionals to help beneficiaries navigate these options, and many also have extensive volunteer networks.
Each year, Medicare has an open enrollment period. In 2020, this will be from October 15 – December 7, 2020, for coverage effective in 2021. During the open enrollment period, Medicare beneficiaries have an opportunity to evaluate and change their Medicare coverage. With the addition of Medicare Advantage plans and a wide range of supplements in recent decades, many Medicare beneficiaries and their representatives seek assistance when enrolling in Medicare for the first time or when making changes to their coverage. SHIP counselors are available to help during this open enrollment period. Kepro has worked with various SHIPs around the country providing “Train the Trainer” presentations to their staff.
“Kepro BFCC-QIO has been a consistent resource and partner for the Texas SHIP for the past 5 years, from providing quarterly trainings to SHIP staff at the local Area Agency on Aging organizations (AAAs) throughout the state and face-to-face trainings at annual SHIP Medicare Improvements for Patients & Providers Act (MIPPA) Conferences to over 200 benefits counselors and ombudsman from all regions of the state. The Kepro Outreach Specialist is always responsive to questions from the SHIP staff as they work and refer beneficiaries throughout the state. Lastly, Kepro has always offered virtual webinars for SHIP counselors and local AAAs staff to ensure that Medicare beneficiaries are aware of all resources available to them when inquiring about services and help with communication with providers.”
- Texas SHIP
“Kepro has been a great community partner to the Georgia State Health Insurance Assistance Program (SHIP). Our mission is to help Medicare beneficiaries, and our collaboration with Kepro has been a win-win for everyone. The Kepro Outreach Specialist, Kia Weaver, is a pleasure to work with, and her professionalism is appreciated. Kia provides an annual webinar to explain the services provided by Kepro to the SHIP statewide network of staff and volunteers. GeorgiaCares SHIP distributes the Kepro flyer to help educate beneficiaries on the services Kepro offers. Kepro has provided a letter of support to SHIP, and we will continue our partnership to help serve Medicare beneficiaries.”
- Georgia SHIP
Publication No. R146810-107-9/2020. 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.