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Case Review Connections

A Newsletter for Healthcare Providers and Stakeholders

Acute Care Edition

Issue 38: November 2023

Do you receive the Case Review Connections newsletter?
If not, sign up for Kepro's email list to receive important news and updates as well as the bi-monthly newsletter.

If you want to communicate BFCC-QIO information, please email 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.

join us for a special webinar about kepro's appeals process

Join us for an informative webinar about Kepro's appeals process taught by Kepro's appeals team on Tuesday, November 28, 2023.

The webinar will provide an overview of Kepro’s appeals process, the reconsideration process, and some tips for success with the appeals process.

Register for the Webinar

If you have difficulty registering, send an email to QIOCommunications@kepro.com.

Aging Health Matters Podcastnew podcast episodes about medicare open enrollment for medicare beneficiaries

Kepro has recently put out three podcasts that focus on Open Enrollment. The podcasts provide information that Medicare beneficiaries will find useful as they are making their Medicare choices for next year. If you work with or have family members that may benefit from these, please pass them along.

Open Enrollment occurs every year from October 15 - December 7. 

in this issue:

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

Kepro has recently released our Annual Reports for 2022 on our website. There are five reports available on Kepro’s website, one for each of Kepro's five regions. These reports have useful information for providers related to Kepro’s beneficiary complaints, hospital discharge and skilled service termination appeals, and Immediate Advocacy. They provide information about the volume of reviews that Kepro has completed for each review type as well as the top 10 medical diagnoses. For beneficiary complaints, the reports list the top categories related to the concerns that were confirmed during the year. For example, the top category in Region 1 was C03: "Apparently did not establish and/or develop an appropriate treatment plan for a defined problem or diagnosis that prompted this episode of care (excludes laboratory and/or imaging." There is also a section sharing the standards of care that Kepro uses to make decisions related to confirming a concern. Lastly, the reports also share the type of issues that were referred to the Quality Innovation Network Quality Improvement Organization (QIN-QIO) for a quality improvement plan. 

For appeal reviews, there is data on the volume of each type of appeal review. For Region 1, the majority of the appeals were for post-acute Medicare Advantage patients, and the least requested review type was the Hospital-Issued Notice of Non-Coverage (HINN) 10 (hospital requests QIO review of a discharge decision without physician concurrence). There is also state-specific data available. Immediate Advocacy is one of Kepro's services that allows our staff to intervene on behalf of a Medicare beneficiary. The reports include Immediate Advocacy success stories and share collaborations by our Outreach staff. 

Overall, the collective data in these reports is used to assist with improving the quality of care that Medicare beneficiaries receive throughout the provider system. To view the report for your region, visit Kepro’s website.

appeals: sharing data  

As we focus on our Annual Reports, we wanted to share data from our appeals department, which allows providers to see the increasing volume that Kepro has seen over the past few years. Providers can also see the appeal types with the most volume.

Completed Appeals: August 2022 - August 2023

The above graph shows the increase in appeal volume from August 2022 (13,077) to August 2023 (18,463) of 41.19%. It also shows the increase in Grijalva (Medicare Advantage) appeal volume from August 2022 (9,611) to August 2023 (14,313) of 48.92%. The August 2023 Grijalva review volume (14,313) exceeded the number of all completed appeals in August 2022 (13,077). 

Completed Appeals: January 2020 to August 2023

The above graph shows the increase in appeal volume since January 2020. It notes: the decline in appeal volume during the initial months of the public health emergency (March - June 2020), a flat line of volume (July - October 2020), and a steady increase in volume since November 2020. The number of completed initial appeals has exceeded 15,000 per month since December 2022. Overall, there has been a 198.75% increase in the number of completed appeals from January 2020 (6,180) to August 2023 (18,463).

become a kepro peer reviewer

Kepro is a nationally recognized provider of healthcare management solutions in both state and federal government as well as commercial clients. We provide prior authorization, utilization and specialty review, and case and disease management services.

To accomplish our objectives, Kepro must have qualified peer reviewers who meet the following criteria:

  • Must be a doctor of medicine, osteopathy, dentistry, podiatry, or optometry, or another individual who is authorized under Federal or State law to practice medicine, surgery, osteopathy, dentistry, podiatry, or optometry 
  • Have a current state license
  • Are board-certified
  • Must either be engaged in active practice in the state or be military physicians who actively practice in a military or Department of Veterans Affairs (DVA) healthcare facility. Active practice means that the physician usually practices (on a routine basis) a minimum of 20 hours per week. Active practice must also include active staff privileges in a healthcare facility on a regular basis. There are some exceptions to this requirement, notably that emergency department physicians and dentists who do not have admitting privileges in an acute care hospital can meet the requirement of active staff privileges as defined in this regulation.

For peer reviewers interested in working with Kepro on Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) reviews, there are three types of cases:

If you have further questions about becoming a peer reviewer or would like additional information, contact our Credentialing Department by email at keprocredentialing@kepro.com.

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 beneficiary’s representative contacted Kepro with concerns about the beneficiary's attending physician at the hospital. The beneficiary had filed an appeal, and the determination was in her favor. She was able to stay and get continued care. However, in the appeal determination provided to the facility, the Kepro peer reviewer had requested a neurological consult, but the attending physician at the hospital refused to do the consult and wrote another discharge order. The representative requested an intervention from Kepro's Immediate Advocacy team to assist with the situation.

The Kepro Clinical Care Coordinator (CCC) made the initial call to the Director of Quality and Patient Safety at the hospital, who left a voicemail in return noting that she had reached out to the beneficiary’s Case Manager. In the voicemail, the Director said that she and the Case Manager were going to discuss the request for a neurological consult with the attending physician. If there continued to be concerns, the Director was going to escalate it to their hospital's Medical Director. The CCC then called the Director back after receiving the voicemail and thanked the Director for her timely response and for advocating for the beneficiary and her family.

The CCC then contacted the representative. The representative was pleased with the outcome and how quickly Kepro had worked for her and her mother.

health equity

The Health Equity Link is a monthly newsletter put out by the Health and Human Services (HHS) Office of Minority Health. It highlights news, campaigns, events, and programs of interest, such as National Hispanic Heritage Month and Health Literacy Month. Since the Centers for Medicare & Medicaid Services (CMS) has made health equity one of their priorities, this newsletter is an opportunity to get more information on their initiatives.

kepro outreach

Kepro’s Outreach Specialists work with various stakeholders in their regions. They can provide training, assist with concerns, and participate in your events. If you are interested in partnering with Kepro, let us know!

new kepro email addresses

Kepro’s employee email addresses will soon be changing....more information coming soon!

Publication No. R146810-322-11/2023. 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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