Case Review Connections
Acute Care Edition
Issue 26: Fall 2021
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One of the responsibilities of the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) is to take complaints about quality of care from Medicare beneficiaries or their representatives. This process involves a medical record review. However, there are some complaints that are better suited for our Immediate Advocacy (IA) service, which is a less formal process.
The Immediate Advocacy process allows the BFCC-QIO to act as a facilitator between the beneficiary/representative and the provider or practitioner.
- The beneficiary or representative calls the BFCC-QIO with a concern.
- The Intake Specialist at the BFCC-QIO recommends the Immediate Advocacy process, if it is appropriate.
- The beneficiary or representative must then give permission for the Intake Specialist to contact the provider or practitioner on his/her behalf.
- This is a voluntary process, so the provider or practitioner must also agree to participate.
- Immediate Advocacy typically involves a phone call and hopefully resolution within a day or so.
Below is an example of an Immediate Advocacy Success Story.
A Medicare beneficiary contacted Kepro with concerns about medical supplies. The beneficiary’s representative, her granddaughter, stated that the managed care company was denying a supply that was needed for a stage 4 pressure wound. The beneficiary had been in the hospital for the past two months, and the hospital staff told her it would be covered. The doctor ordered it for the beneficiary, but the supply company stated it was not covered. The representative requested an intervention by Kepro.
The Clinical Care Coordinator arranged a three-way call with the representative and the medical supply company. The supply company staff stated that the supply would be covered and that it would be delivered in three or four days. The representative was very thankful for Kepro’s support and follow-up.
Immediate Advocacy is typically a quick process and usually results in positive outcomes. One of the benefits for providers is that it may resolve an issue before it escalates into a formal beneficiary complaint.
- For more information about the Immediate Advocacy process, please visit our Immediate Advocacy web page.
- To watch an Immediate Advocacy Success Story video, please visit our YouTube channel.
On its medical record fax sheet, Kepro lists the components of the medical record we require to complete a requested appeal. These components may vary depending on the provider type, but the requirements are listed for the providers’ convenience.
At times, Kepro does not receive all required documents. Rather than close a case for insufficient medical records, we have instituted a process of calling providers to request the missing information be sent to us via electronic submission. Given the expedited nature of these reviews, we ask that the records be sent in within one to two hours of our call. We are currently following this process on weekdays only, as it is very difficult to get a response from providers on weekends.
It is our intention to decrease the “re-work” that must be done by all parties if a case must be closed. The process has been very successful so far, and as a quality improvement organization, we will continue to look for ways to improve the appeal experience for all stakeholders.
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 contacted Kepro with concerns about not being able to get treatment at the hospital. The beneficiary went to the emergency department at the hospital with searing pain. The beneficiary had to walk a long distance to the treatment room. She asked for a wheelchair and was told that none were available. She was finally given a lounger with wheels but had to transfer to another chair once she reached the treatment room. The chair she was given to sit in was so uncomfortable, so she asked for other accommodations and was told there was nothing else available. She finally decided to leave because she could not take the pain any longer. She called Kepro to complain and was told that the issues she discussed would not be available in the medical record. However, she was offered the opportunity for Immediate Advocacy to address her concern.
The Clinical Care Coordinator (CCC) was able to conference call with an urgent care center a few blocks from the beneficiary’s home. The facility staff confirmed that they would take the beneficiary’s insurance and stated that the waiting room was not busy at all. The beneficiary was extremely appreciative and said she was going to go to the urgent care as soon as the call was complete.
Per the Centers for Medicare & Medicaid Services (CMS), “through the Community Health Access and Rural Transformation (CHART) Model, CMS aims to continue addressing disparities by providing a way for rural communities to transform their health care delivery systems by leveraging innovative financial arrangements as well as operational and regulatory flexibilities.” If you are interested in receiving additional information and updates about the CHART and to learn more about how CMS is addressing rural disparities, please subscribe to the CHART listserv.
One of the roles of Kepro Outreach staff is to build relationships and collaborate with county health departments. These organizations help distribute BFCC information to their stakeholders, to ensure that they are aware of the services that Kepro provides. If you are a partner or stakeholder and are interested in collaborating with Kepro, please reach out to the Outreach Specialist for your state. Below is a testimonial from a county health department in Utah.
The Davis County Health Department/Area Agency on Aging has had an excellent working relationship with Kepro's Outreach Team. As a health department, we run a county-wide Coalition for Abuse Prevention of the Elderly (CAPE) which is a multi-disciplinary team focused on alleviating the effects of elder abuse in our community. Kepro gave a wonderful presentation to our coalition, which is comprised of Area Agency on Aging staff, local law enforcement, Adult Protective Services, victim advocates, domestic violence services, and many other community partners. As a result of this interaction, we were able to help promote Kepro in many of our county-wide newsletters. Kepro also was able to help me personally when my mother-in-law was being prematurely discharged from a long-term care facility by providing me with timely information and walking me through the appeal process.
- Davis County Health Department, Utah
Publication No. R146810-218-10/2021. 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.