Case Review Connections Acute Care Edition Issue 19: Winter 2019 |
If you want like to communicate BFCC-QIO information, please contact KEPRO at KEPRO.Communications@kepro.hcqis.org and request a newsletter insert or fact sheet for your organization. Please do not copy and paste information from Case Review Connections.
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In this issue:
medical director's corner
As a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), one of KEPRO’s roles is to review quality of care concerns. These concerns may come from beneficiary complaints or may arise during other types of reviews, such as appeals. When KEPRO identifies a potential quality of care concern, the provider or practitioner is given an opportunity to respond before a concern is confirmed. Please know that the quality review is not meant to be punitive but is done in a spirit of collegiality and quality improvement. KEPRO does not typically report this type of information to other oversight agencies, and our reviews are covered under federal confidentiality regulations.
I wanted to share some tips that will assist providers and practitioners with their response to this type of correspondence should you or your facility receive it:
- KEPRO sends letters to the address that is listed in the Medicare database.
- Time frames must be adhered to because they are provided by the Centers for Medicare & Medicaid Services (CMS). As a CMS contractor, we must enforce them.
- Please respond to the questions as specifically as possible with the necessary clinical information. KEPRO’s Physician Reviewer will receive the response and determine if the concern will be resolved or confirmed.
- KEPRO will notify you or your facility with the review determination.
- Please take the correspondence seriously and respond by the time frame noted.
appeals and qmars
When KEPRO began its new contract in June 2019, BFCC-QIOs were required to use CMS’ designated case review system, QMARS, for all of its mandatory review work. After using the system for four weeks and experiencing multiple challenges, KEPRO reverted to its internal appeal review system on July 15, 2019. KEPRO has continued to use QMARS for quality of care and EMTALA reviews along with its Sanction activities, since the transition in June.
KEPRO has been working with CMS on system enhancements and testing over the past several months and anticipates returning to QMARS for the appeal reviews within the next month, due to CMS requirements. Once a transition date has been determined, KEPRO will keep the provider community informed through email communication and our website, www.keproqio.com. The helplines will continue to offer a dedicated provider prompt to streamline communication. Please know that KEPRO is working diligently with CMS to make this transition as seamless as possible in hopes to create little to no impact on the providers and beneficiaries we serve.
Important Note: Fax numbers will change once KEPRO transitions back to QMARS. The new fax numbers will be available at www.keproqio.com and on the medical record request sent to your organization.
Reminder: Please include the medical record request sheet containing the barcode when faxing medical records. This automatically attaches your medical records to the case in QMARS, which decreases the turnaround time on reviews.
memorandum of agreement update
Effective June 8, 2019, the states served by KEPRO changed. CMS requires all providers to complete a new Memorandum of Agreement (MOA) for each facility with a separate NPI or CCN, even if one was submitted to KEPRO prior to June 8, 2019. MOAs outline the BFCC-QIO’s and provider’s responsibilities during the review process. If you have not submitted an MOA, visit the KEPRO MOA website page to review and sign your facility’s agreement as well as review an FAQ with additional information regarding MOAs.
KEPRO suggests using Google Chrome internet browser, the latest version of Adobe Reader, and completing the form in one sitting. If forwarding to an administrator for signature, please select “Finish Later” and enter the administrator’s email for signature. Please contact moa@kepro.com with questions or for further assistance.
email address change
The email addresses for KEPRO’s staff will be changing on or around the first of the year. If you frequently correspond with someone at KEPRO, please reach out to him or her for their new email address. The new standard format will be first initial then last name (e.g., Mary Smith – msmith@kepro.com). QIOcommunications@kepro.com is the new email address for general correspondence and concerns. If you have difficulty determining the email address for one of our staff, contact KEPRO Communications email for assistance.
immediate advocacy success story
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 representative called KEPRO with concerns about his latest hospital stay. He was admitted after an appointment with his cardiologist. During his hospital stay, he had multiple procedures; however, the representative felt that the patient was not provided with appropriate discharge planning because home health services were not set up and needed medical equipment wasn’t received. The representative requested assistance from KEPRO.
The Clinical Care Coordinator (CCC) at KEPRO called the hospital case management department. The CCC then was then directed to a social worker to resolve the discharge planning concerns. After the CCC worked things out with the social worker, she contacted the representative who confirmed that home health services had been set up, and the medical equipment issues were resolved. The representative was pleased with the outcome, and no further assistance was needed. The family was very appreciative that an organization was available to help them as they were navigating through the healthcare process.
frequently asked questions
Q. | If a Medicare beneficiary has a representative, can he/she be notified by telephone about a discharge/service termination? |
A. | Yes. The following information should be included during that phone call:
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Q. | What if the Medicare beneficiary did not fully read their appeal notice and has already been discharged from the facility? Is there any way to do an appeal after he/she has already left the facility? |
A. | If a Medicare beneficiary felt that the discharge was not appropriate, he/she could file a quality of care complaint about a premature discharge. Beneficiaries cannot appeal to stay longer after they have left the facility. They can only file an appeal related to financial liability after discharge. |
staff education about bfcc-qio services
KEPRO’s Outreach Specialists can provide value to your facility or organization by sharing relevant information and updates via joint presentations, quarterly staff trainings, webinars, conference calls, and advisory boards. Visit KEPRO’s website for details.
Publication No. AXXX-XXX-12/2019. 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.