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Case Review Connections 

Post-acute Care Edition

Issue 26: Fall 2021

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If not, sign up for Kepro's email list to receive important news and updates as well as the quarterly newsletter.

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.

join us for a webinar

Join our Outreach staff for an informative webinar about Kepro on Wednesday, November 3, 2021. The webinar will provide basic information about the services that Kepro offers for Medicare beneficiaries:

  • Quality of care complaints,
  • Appeals, and
  • Immediate Advocacy services.

Register for the Webinar

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

Health Literacy

in this issue:

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

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.

appeals: collecting required components of the medical record

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 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 contacted Kepro with concerns about his mother-in law’s physical therapy. The physical therapist at the facility did more therapy than was ordered, and the beneficiary was injured. She was taken to see her doctor, and he ordered her to be off her feet for one week. However, when the week was up, she was not given therapy again. Then the facility issued a Notice of Non-Coverage. The representative filed an appeal but also requested an intervention to get some answers.

The Clinical Care Coordinator then contacted the facility. She explained the circumstances that the representative had shared. There were some back and forth phone calls between the facility and Kepro regarding what had happened. The notice was eventually rescinded, and the representative was appreciative of Kepro’s efforts to resolve the situation.

chart model

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.

outreach testimonial: health departments

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. R146810-219-10/2021. 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. 

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