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KEPRO is responsible for various mandatory reviews as part of its a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) contract. These other reviews include Higher Weighted Diagnosis-Related Group (DRG) reviews, EMTALA reviews, Referral reviews, Short Stay reviews, and Assistant at Cataract reviews.
Higher Weighted DRGs
Hospitals may submit requests for Higher Weighted Diagnosis-Related Group (DRG) assignments directly to their Medicare Administrative Contractor (MAC) for processing and payment. All such requests granted by the MAC are subsequently selected by the Centers for Medicare & Medicaid Services (CMS) for BFCC-QIO review on a post-payment basis. As specified in 42 CFR §412.60(d)(2) and 42 CFR §476.71, BFCC-QIOs review hospital-requested Higher Weighted DRG assignments for medical necessity, quality, and DRG validation.
The purpose of DRG validation review is to ensure that the diagnostic and procedural information and the discharge status of the patient matches both the attending physician’s description and the information contained in the patient’s medical record.
Adjustments reported by the BFCC-QIO have no corresponding time limit and are adjusted automatically by the MAC without requiring the hospital to submit an adjustment bill.
KEPRO conducts a five-day medical advisory review upon request from the appropriate CMS regional office. KEPRO’s physician conducts a medical assessment of a potential Emergency Medical Treatment and Active Labor Act (EMTALA) violation case as specified in Part 9 of the QIO Manual (Attachment J-4). The five-day review is not mandated by the federal statute and regulations. However, the regional office may use this review as a resource in making a compliance determination, rather than simply determining the merits of the complaint.
Under sections 1867(d)(3) of the Act and 42 CFR §489.24(g), KEPRO is required to conduct a 60-day review upon receipt of a completed EMTALA case sent to the Office of the Inspector General for possible civil monetary penalty or exclusion sanction as outlined in Part 9 of the QIO Manual.
BFCC-QIOs are required to conduct quality reviews when complaints about Medicare beneficiaries' healthcare are received from sources other than the beneficiary. These referrals come from a variety of state and federal agencies and organizations that include, but are not limited to:
- the Office of the Inspector General (OIG);
- the Federal Bureau of Investigation (FBI);
- the Centers for Health Dispute Resolution (CHDR);
- the Joint Commission; and
- Medicare Administrative Contractors (MAC).