Case Review Connections
Post-acute Care Edition
Issue 25: Summer 2021
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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.
Every year, the Centers for Medicare & Medicaid Services (CMS) requires Kepro to produce Annual Reports, which give information about the volume and outcomes of Kepro’s review activity. There are five reports available online, one for each of Kepro's five regions.
The first section of the report has global data followed by an appendix that contains data for each state in that Region. The report includes the total volume of reviews, the top 10 diagnoses for Medicare claims in that Region, the provider settings associated with beneficiary complaints, and the type of quality of care concerns and corresponding outcome identified during medical record reviews. Information about the outcomes of hospital discharge and skilled service termination appeals is available. There is also a section in the report about the standards of care that Peer Reviewers use to make their clinical decisions.
Immediate Advocacy is one of Kepro's services that allows our staff to intervene on behalf of a Medicare beneficiary; it has been used frequently during the pandemic. The report includes Immediate Advocacy success stories and shares collaborations by our Outreach staff. The collective data in these reports is used to assist with improving the quality of care that Medicare beneficiaries receive throughout the provider system.
When a Medicare beneficiary is not competent to receive the Notice of Medicare Non-Coverage (NOMNC), the facility will need to provide the notice to his/her representative. If the representative is not available in person, the notice will need to be given by phone. For the verbal NOMNC to be valid, the information below must be provided to the representative and included in the telephonic notice documentation:
- Beneficiary’s name
- Date and time called
- Facility representative that relayed the information
- Beneficiary representative name
- Beneficiary representative phone number
- Effective date (last day of coverage)
- Liability date
- QIO telephone number
- Appeal deadline
- What to do if the deadline is missed
- If there is a Medicare Advantage (MA) plan, include the plan telephone number
- Signature/title/date of the facility representative
The date the facility conveys this information to the representative, whether in writing or by telephone, is the date of receipt of the notice. Confirm the telephone contact by mailing the written notice on that same date. Place a dated copy of the notice in the beneficiary’s medical file and document the telephone contact with the beneficiary’s representative (as listed above) on either the notice itself or in a separate entry in the beneficiary’s file or attachment to the notice.
The documentation should indicate that the staff person told the representative the effective date, the beneficiary’s appeal rights, and how and when to initiate an appeal. The documentation should also include the name of the staff person initiating the contact, the name of the representative contacted by phone, the date and time of the telephone contact, and the telephone number called.
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 the beneficiary’s home health care services. She was concerned about the therapist’s care as well as the lack of time spent with the beneficiary (30 minutes instead of the hour allotted). She requested an intervention by Kepro to assist with a transfer to another agency.
The Clinical Care Coordinator (CCC) contacted the manager at the home health agency. The manager stated that the family did not want to follow the plan of care and that they had been difficult to work with. She stated that she would have a social worker visit as well as check the beneficiary’s insurance and then make a referral to another agency. The CCC then contacted the beneficiary’s representative to let her know the outcome of the intervention, and she was pleased.
Kepro has advocacy resources available to help educate Medicare beneficiaries about their Medicare rights. This helps to ensure that they get the healthcare services they need and also to make sure that the care they receive is appropriate. Kepro's news insert will help you share information in your newsletter and on your website. A short and long version is available, so choose the one that will best suit the needs of your organization.
Kepro has a webpage with COVID-19 resources from CMS and the Centers for Disease Control and Prevention. Resources include tool kits, fact sheets, weblinks, and trainings.
Rural health is a continuing area of focus for CMS. Some of the challenges for rural health include hospital closures and practitioner shortages. With that in mind, CMS recently summarized their initiatives to address these issues as well as sharing accomplishments in Rethinking Rural Health, 2020 Year in Review.
One of the roles of Kepro Outreach staff is to build relationships and collaborate with provider associations, including hospital, skilled nursing and home health, and hospice associations. These organizations help distribute timely BFCC information to their providers to ensure providers are kept up with the necessary information needed to do their jobs. An example of this would be when CMS recently switched to electronic medical record submission. Provider associations were very helpful in getting the message out.
“SCHA and the member hospital case management staff have experienced a phenomenal working relationship with Kepro. The team has always willingly participated on teleconferences to address new processes as well as issues encountered with the review process for inpatients. We feel very fortunate to work with such a professional organization and hope to continue the process ensuring the best for all SC Medicare beneficiaries.”
- South Carolina Hospital Association
"The Texas Health Care Association has worked collaboratively with Kepro and the Outreach Specialist for more than four years. Kepro has continuously provided education and outreach to our providers who are members of our association. The Outreach Specialist has also worked closely with the THCA staff to ensure that we are always “in the know” with vital information to send out to providers when changes occur. In the past, Kepro has attended and presented at the THCA summer conferences that host over 500 providers from all over the state. However, with the rise of the pandemic, Kepro has continued these educational efforts virtually through webinar presentations and conference calls. The Kepro Outreach Specialist's willingness to answer and mitigate questions that may arise from various providers shows that Kepro is trying to ensure that providers and beneficiaries have accurate and up-to-date information."
- Texas Health Care Association
Does your staff need to learn more about Kepro services?
Visit our Schedule a Speaker page to request a presentation and contact information for the Outreach Specialist for your region.
Join our Outreach staff for an informative webinar about Kepro on September 22, 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.
If you have difficulty registering, please email QIOCommunications@kepro.com.
Publication No. R146810-213-7/2021. 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.