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Case Review Connections 

Post-acute Care Edition

Issue 28: March 2022

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If you want to communicate BFCC-QIO information, please contact Kepro at QIOCommunications@kepro.com and request a newsletter insert or fact sheet for your organization. Please do not copy and paste information from Case Review Connections.

resources for the medicare beneficiaries you serve

New Newsletter. On the Healthcare Front is a newsletter to help Medicare beneficiaries and their families learn about their Medicare rights and how to get the most out of their health care. Read more about the newsletter or sign up: On the Healthcare Front newsletter

YouTube Videos. Kepro has a new YouTube video -  how to fill out the quality of care form that is necessary to file a beneficiary complaint. 

appeals cases

If you are looking for your appeal determination - or where the appeal is in the process - please use the Case Status tool on our website. The information is up to date, and the tool is very easy and convenient to use.

march is national nutrition month

Visit our nutrition month page for resources to share with Medicare beneficiaries.

Photo of healthy food in a jar

in this issue:

medical director's corner - jessica whitley, md, mba

One of Kepro’s functions as a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) is to conduct quality of care reviews.

These reviews can come from

  • Medicare beneficiary complaints,
  • referrals from other subcontractors, or
  • other BFCC-QIO reviews, such as appeals.

Quality of care reviews with either a Gross & Flagrant determination or a Substantial Number of Substantial Violations determination, could become eligible to be referred for Sanction to the Office of the Inspector General (OIG). When this happens, the review takes a different path than a regular quality of care review.

In this column, I wanted to share the process that occurs if you or your facility gets correspondence related to a potential Sanction. Please know that this process is meant to be collegial and to improve the quality of care. It is not meant to be punitive.

  1. Once the possible Sanction determination comes back from the Peer Reviewer, it is sent to two other Peer Reviewers.
  2. If two out of three Peer Reviewers agree regarding the possible Sanction determination, the provider is notified of the findings and is provided with the opportunity to respond in writing or to have a face-to-face meeting with Kepro.
  3. If the provider requests a face-to-face meeting, staff members from Kepro will meet with the provider along with the Sanction panel. The Sanction panel is made up of physicians who will assist Kepro in determining whether the case truly is a possible Sanction case.

If the concerns are determined not to be Gross & Flagrant or Substantial Number of Substantial Violations after the written explanation or the meeting, then the case will revert to a regular quality of care review.

If the concerns are determined to be confirmed as Gross & Flagrant or Substantial Number of Substantial Violations, the provider/practitioner will be required to submit a Corrective Action Plan (CAP). This may include submitting data to Kepro over a required time period, such as a year. Once the CAP has been completed to the satisfaction of Kepro, the case will be complete. If the CAP is not completed appropriately, the case may be recommended for Sanction to the OIG.

For more information about the Sanction process, please see Chapter 9 of the Quality Improvement Organization Manual: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/qio110c09.pdf.



Kepro is pleased to announce a revamped notification system for appeal determinations. In addition to Kepro’s online case status tool, which provides real-time updates showing where the appeal is in the review process, providers will now receive automated faxes with immediate notification of appeal determinations within 30 minutes of Kepro notifying the beneficiary or their family. Moving forward, telephonic notification will be made to Medicare beneficiaries only. This streamlined approach will continue to provide instant communication to keep providers informed during the review process through fax notification. Please note – determination letters will be sent to the fax number used for the medical record request.


 Please contact Kepro’s Helpline with any questions. Find the toll-free number for your state at www.keproqio.com/helpline.

frequently asked questions

Q: When are medical records due after an appeal has been requested?
A: The medical records are due by close of business on the day the appeal has been requested.

Q: Where are the Centers for Medicare & Medicaid Services (CMS) notices available?
A: They are available at the CMS Beneficiary Notices Initiative webpage.

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 her mother’s discharge from the skilled nursing facility. She had filed an appeal, which went in favor of the provider, and she felt she did not have time to get the equipment in place before her mother returned to her home. She needed a hospital bed delivered and set up and felt that no one was assisting her. She asked Kepro for assistance.

Kepro’s Clinical Care Coordinator called the facility and left a message about the situation. Kepro received a message back that the hospital bed would be in place before the beneficiary was discharged. Kepro then contacted the representative who confirmed that the hospital bed was set up for delivery. The representative was extremely appreciative of the call and the assistance that Kepro provided.

cms quality conference: register

The Centers for Medicare & Medicaid Services (CMS) will be having its annual Quality Conference on April 12 and 13, 2022. The event will be virtual, and the theme is “New Hope, New Health: Charting a Path Forward.” Watch this video for a sneak peak of what you can expect from the conference.

For more information, visit www.cmsqualityconference.com.

rural health resources

CMS has compiled a list of resources for rural health providers.

outreach and health equity

Kepro’s Outreach Specialist is a participating member of the Massachusetts Senior Medicare Patrol (SMP) Program Advisory Committee. The MA SMP Program Advisory Committee educates Medicare beneficiaries, particularly hard-to-reach, low income, underserved, rural and other isolated and vulnerable populations, their family members, and caregivers about the importance of being engaged healthcare consumers. 

Kepro’s Outreach Specialist presented at a workshop during the MA SMP’s Ninth Statewide Conference. The theme of the conference was Engagement & Inclusion = Health Equity & Quality. The goal of the conference was to encourage Medicare beneficiaries and caregivers to become actively engaged in their health care. Kepro’s Outreach Specialist provided resources to stakeholders on Immediate Advocacy services that are available to Medicare beneficiaries, which are particularly useful for those in rural areas.

Kepro is currently actively working to develop partnerships with the Institute for Healthcare Improvement in Region 1 as well as the Georgia Office of Minority Health, the Healthcare Georgia Foundation, and the Partnership for Southern Equity in Region 4. Kepro also plans to collaborate with CMS on their rural health efforts going forward.

Publication No. R146810-237-3/2022. 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. 

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