Case Review Connections
Acute Care Edition
Issue 27: January 2022
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youtube: videos for providers and patients
Kepro has added another Immediate Advocacy success story video to our YouTube channel. Please share with people who have Medicare to help them better understand this free service for times when they may need assistance with their health care in the future.
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One of the responsibilities of the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) is to accept referrals from other Centers for Medicare & Medicaid Services (CMS) contractors.
One contractor that frequently refers cases is the Zone Program Integrity Contractor (ZPIC). The role of the ZPIC is to prevent, detect, and deter Medicare fraud, and they have access to a large spectrum of providers and practitioners. While they are doing their investigation related to fraud, the ZPIC may uncover potential quality of care issues that need to be addressed by the BFCC-QIO. Other examples of referral contractors include CMS, the Office of the Inspector General (OIG), and Medicare Administrative Contractors (MAC).
Once a case is referred to the BFCC-QIO, it is performed as a general quality review. These general quality reviews have a different process than a beneficiary complaint. The provider/practitioner only has an opportunity for a reconsideration if a possible quality of care concern is found. It also means that there is no disclosure to the beneficiary or family regarding the findings. If a quality concern is confirmed, the provider/practitioner may be referred to the Quality Innovation Network Quality Improvement Organization (QIN-QIO) for additional quality improvement monitoring.
Please visit the Other Reviews page on Kepro's website for more information about the other types of reviews that Kepro is responsible for besides appeals and the beneficiary complaint process.
As a reminder, since October 2020, CMS has required providers to send medical records to Kepro electronically. If providers are not able to comply with this requirement, they must request a waiver from Kepro.
Approved waivers expire on the last day of the calendar year (12/31/2021) and must be renewed yearly. If medical records are not sent by the approved method without a waiver, they will not be reimbursed.
- Get the waiver form
- Visit Medical Record Electronic Submission page for information about the submission process, including waiver information, frequently asked questions, or reimbursement information
- Watch our YouTube video, Electronic Medical Record Submission
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 shares success stories with providers to show how this process can benefit providers by working together and resolving problems quickly, which can lead to improved patient relations.
A beneficiary’s representative contacted Kepro with concerns about her mother. She had been at a long-term acute care facility but had to be transferred back to the hospital due to multiple complications. When she was ready to leave the hospital, the previous facility would not accept her back because of all of her conditions. She was told that her mother would be eligible for hospice. She requested help from Kepro to better understand the situation and assist with the plan of care for her mother.
The Clinical Care Coordinator contacted the hospital’s social worker, who updated her on the situation with the beneficiary. The social worker agreed that the beneficiary would be able to stay at the hospital until everything necessary was in place for hospice at the home. Kepro then spoke to the beneficiary’s representative to give her an update from the hospital social worker. The representative stated that she did want hospice.
Kepro contacted the social worker again to let her know to proceed with hospice. The social worker stated that equipment should be able to be delivered by the next day, and the beneficiary could discharge the day after that. The social worker also stated the representative would be given the appropriate training for the equipment and for any procedures that she may need to do. Kepro made a final follow-up phone call with the representative to make sure the transition had gone as planned and that she and her mother had everything they needed. She stated that she had received the proper training and that the equipment had been delivered. She was very happy with the results of the intervention.
CMS recently released their rural health report for 2021 titled “Improving Health in Rural Communities: 2021 Year in Review.” Per CMS, “this report emphasizes CMS’ commitment to working with rural communities to address barriers and build on existing advancements to achieve optimal outcomes for all rural Americans.”
One of the roles of Kepro Outreach staff is to build relationships and collaborate with providers and stakeholders. They work directly with community partners to ensure Medicare beneficiaries have the information they need about their Medicare rights. Kepro’s Outreach Specialists are available for presentations and education about Kepro’s services. We hope that you will take advantage of their expertise and contact the Outreach Specialist for your state to collaborate with your organization.
Working with CMS. Recently, one of our stakeholders, the CMS Atlanta Regional office, shared about their experience with one of the Outreach Specialists. They noted that Kepro’s Outreach Specialist is always willing to volunteer and participate in their Outreach efforts to educate beneficiaries, Congressional offices, and CMS staff. Kepro’s Outreach Specialist keeps their office abreast of any changes at Kepro while providing beneficiary flyers, contact information, and information about upcoming webinars. They shared how much they value the collaborative partnership and will continue building it to educate the Medicare community on the great work that Kepro is doing to improve the lives of Medicare beneficiaries and their families.
Working with Senior Medicare Patrol (SMP). The Massachusetts SMP shared that Kepro is an important partner in their efforts to make sure that quality of care is at the center of every medical intervention for every Medicare beneficiary. They also routinely refer consumers to Kepro when quality of care is a concern and stated that they look forward to exploring more avenues for partnering.
Working with the Media. Kepro has also had some unique Outreach events this quarter, serving as a guest on a podcast and a TV show. Both were an opportunity to reach a wider audience with the information about Kepro’s services for Medicare beneficiaries and their families. If you would like to view these Outreach presentations, the links are below:
Publication No. R146810-226-1/2022. 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.