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Case Review Connections 

Acute Care Edition

Winter 2019 

Issue No. 17



Welcome to the winter edition of the Case Review Connections, a quarterly e-newsletter from your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). We hope you find Case Review Connections informative and welcome new topics you would like to see featured.

Medical Director's Corner - Ferdinand Richards III, MD

KEPRO recently posted its Annual Reports for year four of its Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) contract. There is one report for each of KEPRO’s three service areas, and each report provides data on the volume and outcomes of KEPRO’s case review activity. Some of the information provided in these reports includes the number of reviews, review settings, quality of care concerns confirmed, referrals to the Quality Innovation Network (QIN) QIOs, and information about discharge and service terminations. KEPRO also provides information about the standards of care used by its Peer Reviewers in making their clinical decisions as well as Immediate Advocacy success stories and information about our collaborations by our Outreach staff.

In the appendix at the end of the report is statewide data. This gives a glimpse into the review activity for each of KEPRO’s 33 states as well as the District of Columbia. These reports provide collective data that can be used to improve the quality of care throughout the provider system based upon the experiences of Medicare beneficiaries.

Patient Navigation Program Update

KEPRO began a Patient Navigation program in fall 2017 as part of its Person and Family Engagement project with the Centers for Medicare & Medicaid Services (CMS). The program has helped over 14,000 Medicare beneficiaries transition from one care setting to another. As a result of KEPRO’s current contract with CMS coming to a close, the Patient Navigation program will be ending. KEPRO is not able to continue enrolling Medicare beneficiaries into the Patient Navigation program but will continue providing service to beneficiaries already enrolled in the program through April 30, 2019, to ensure all of their needs are met.

It is KEPRO's understanding that CMS has future plans to implement another Patient Navigation program. KEPRO does not have any further details at this time.

Please contact the KEPRO Outreach Specialist for your state with any questions or for further assistance.

New Medicare Cards

New Medicare cards have all been mailed out. More information is available on the Centers for Medicare & Medicaid Services (CMS) website.

Immediate Advocacy Success Story

Immediate Advocacy is an informal process in which KEPRO acts as a liaison for a Medicare beneficiary or his or her representative to quickly resolve a verbal complaint. Below is an example of a KEPRO success story.

A Medicare beneficiary contacted KEPRO with concerns about refills for her oxygen tank and obtaining 50 foot tubing for the equipment. She stated that the oxygen tank refills should have arrived over a week ago, and every time she called, she was told the driver was out for delivery. No one showed up, and they kept rescheduling her with no tanks ever arriving. She asked for an intervention by KEPRO.

The KEPRO Clinical Care Coordinator (CCC) contacted the durable medical equipment (DME) company. The representative stated that it was noted that the tanks had been delivered earlier that day along with the tubing. The CCC then contacted the beneficiary to see if she had received the equipment. She stated that the tanks had arrived, but she still did not receive the tubing. The CCC contacted the DME representative and explained that the delivery driver did not have any tubing on the truck, so they will send the tubing by FedEx via next day delivery. The CCC then followed up with the beneficiary and told her to call if she did not receive the tubing that was ordered. The beneficiary was appreciative of the assistance from KEPRO.

Hospital Discharge Appeals

Please remember how important it is to keep your appeals contact information up to date. Sometimes when KEPRO calls facilities, especially on holidays and weekends, the contact listed in our system no longer works at the facility or only works Monday thru Friday. Sometimes voicemail picks up, and it is an unsecured personal cell phone, so no message can be left. Then the facility has to be called, and the call may be forwarded several times before the correct person is reached.

Since appeals are under a strict time frame, it helps both KEPRO and the facility under review to make sure that the correct person can be reached in a timely manner. To find out who at your facility is listed as a point of contact, please call KEPRO’s Helpline to speak with a representative. If you need to update your organization’s contact information, please use the appropriate form located on KEPRO’s website.

Higher Weighted DRGs

As part of the review process for Higher Weighted Diagnosis-Related Group (HWDRG) claims, medical record evaluations are conducted to verify appropriate documentation exists to support the DRG change and admission. If a discrepancy is found that does not support the requested change, notification is sent to the provider to allow for additional written correspondence to support the requested change. However, if the requested changes are approved, no communication is sent to the provider per the CMS Medicare QIO Manual.

Short Stay Reviews

“This MLN Matters® article highlights the rules for inpatient admission under the Two-Midnight rule for acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities submitting Short Stay inpatient claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.”

Acute Care Frequently Asked Questions

Q. What is the monetary threshold for 2019 to request a hearing with an Administrative Law Judge?

A. The amount for 2019 remains at $160, which is the same as 2018.

Q. What is a Medicare benefit period?

A. A benefit period begins the day that a beneficiary goes to the hospital or skilled nursing facility. It ends when a beneficiary has not received inpatient hospital care or skilled care in a skilled nursing facility for 60 days in a row.

Save the Date!

Join us for a BFCC-QIO webinar! KEPRO is the BFCC-QIO for over 30 states. We offer three FREE services to Medicare beneficiaries and their families: beneficiary complaints, discharge appeals, and Immediate Advocacy. This webinar will present a basic overview of these services.

What: KEPRO's Free Services for Medicare Beneficiaries

Who: Healthcare providers and stakeholders

When: March 27, 2019, 2 p.m. – 3 p.m. ET

Speakers: Kia Weaver, MPH, Outreach Specialist, KEPRO; Sylvia Gaddis, Outreach Specialist, KEPRO

Register Now!

When: March 28, 2019, 2 p.m. – 3 p.m. ET

Speakers: Shannon Sheppard, MPH, Outreach Specialist, KEPRO; Andrea Plaskett, MPH, Outreach Specialist, KEPRO

Register Now!

Publication No. A234-730-2/2019. 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. The information contained in this document is conditionally valid through July 2019.

Please do not copy/paste information from Case Review Connections. If you’d like to communicate BFCC-QIO information, please contact KEPRO at KEPRO.Communications@hcqis.org.


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