Case Review Connections
Post-acute Care Edition
Issue 27: January 2022
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youtube: videos for providers and patients
Kepro has added another Immediate Advocacy success story video to our YouTube channel. Please share with people who have Medicare to help them better understand this free service for times when they may need assistance with their health care in the future.
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One of the responsibilities of the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) is to accept referrals from other Centers for Medicare & Medicaid Services (CMS) contractors.
One contractor that frequently refers cases is the Zone Program Integrity Contractor (ZPIC). The role of the ZPIC is to prevent, detect, and deter Medicare fraud, and they have access to a large spectrum of providers and practitioners. While they are doing their investigation related to fraud, the ZPIC may uncover potential quality of care issues that need to be addressed by the BFCC-QIO. Other examples of referral contractors include CMS, the Office of the Inspector General (OIG), and Medicare Administrative Contractors (MAC).
Once a case is referred to the BFCC-QIO, it is performed as a general quality review. These general quality reviews have a different process than a beneficiary complaint. The provider/practitioner only has an opportunity for a reconsideration if a possible quality of care concern is found. It also means that there is no disclosure to the beneficiary or family regarding the findings. If a quality concern is confirmed, the provider/practitioner may be referred to the Quality Innovation Network Quality Improvement Organization (QIN-QIO) for additional quality improvement monitoring.
Please visit the Other Reviews page on Kepro's website for more information about the other types of reviews that Kepro is responsible for besides appeals and the beneficiary complaint process.
As a reminder, since October 2020, CMS has required providers to send medical records to Kepro electronically. If providers are not able to comply with this requirement, they must request a waiver from Kepro.
Approved waivers expire on the last day of the calendar year (12/31/2021) and must be renewed yearly. If medical records are not sent by the approved method without a waiver, they will not be reimbursed.
- Get the waiver form
- Visit Medical Record Electronic Submission page for information about the submission process, including waiver information, frequently asked questions, or reimbursement information
- Watch our YouTube video, Electronic Medical Record Submission
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 shares success stories with providers to show how this process can benefit providers by working together and resolving problems quickly, which can lead to improved patient relations.
A beneficiary’s representative contacted Kepro with concerns that his mother was being discharged from the skilled nursing facility. He explained the situation to the Kepro Clinical Care Coordinator. He did not know what to do and asked Kepro to help.
Kepro set up a conference call with the social worker at the facility. She explained that the representative filed the appeal too late with Kepro, so the appeal now needed to be filed through the managed care plan.
Kepro spoke with the representative to explain the situation and to be sure he had all needed information. He stated that he would be in touch with the social worker to complete any necessary paperwork to get that appeal started. Kepro made sure that all parties had the correct contact information in case any additional assistance was needed. The representative was very satisfied with the assistance provided by Kepro.
CMS recently released their rural health report for 2021 titled “Improving Health in Rural Communities: 2021 Year in Review.” Per CMS, “this report emphasizes CMS’ commitment to working with rural communities to address barriers and build on existing advancements to achieve optimal outcomes for all rural Americans.”
One of the roles of Kepro Outreach staff is to build relationships and collaborate with providers and stakeholders. They work directly with community partners to ensure Medicare beneficiaries have the information they need about their Medicare rights. Kepro’s Outreach Specialists are available for presentations and education about Kepro’s services. We hope that you will take advantage of their expertise and contact the Outreach Specialist for your state to collaborate with your organization.
Working with CMS. Recently, one of our stakeholders, the CMS Atlanta Regional office, shared about their experience with one of the Outreach Specialists. They noted that Kepro’s Outreach Specialist is always willing to volunteer and participate in their Outreach efforts to educate beneficiaries, Congressional offices, and CMS staff. Kepro’s Outreach Specialist keeps their office abreast of any changes at Kepro while providing beneficiary flyers, contact information, and information about upcoming webinars. They shared how much they value the collaborative partnership and will continue building it to educate the Medicare community on the great work that Kepro is doing to improve the lives of Medicare beneficiaries and their families.
Working with Senior Medicare Patrol (SMP). The Massachusetts SMP shared that Kepro is an important partner in their efforts to make sure that quality of care is at the center of every medical intervention for every Medicare beneficiary. They also routinely refer consumers to Kepro when quality of care is a concern and stated that they look forward to exploring more avenues for partnering.
Working with the Media. Kepro has also had some unique Outreach events this quarter, serving as a guest on a podcast and a TV show. Both were an opportunity to reach a wider audience with the information about Kepro’s services for Medicare beneficiaries and their families. If you would like to view these Outreach presentations, the links are below:
Publication No. R146810-227-1/2022. 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.