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KEPRO is responsible for various mandatory reviews as part of its a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) contract. These other reviews include EMTALA reviews, Referral reviews, and Assistant at Cataract reviews.
KEPRO conducts a five-day medical advisory review upon request from the appropriate CMS regional office. KEPRO’s physician conducts a medical assessment of a potential Emergency Medical Treatment and Active Labor Act (EMTALA) violation case as specified in Part 9 of the QIO Manual (Attachment J-4). The five-day review is not mandated by the federal statute and regulations. However, the regional office may use this review as a resource in making a compliance determination, rather than simply determining the merits of the complaint.
Under sections 1867(d)(3) of the Act and 42 CFR §489.24(g), KEPRO is required to conduct a 60-day review upon receipt of a completed EMTALA case sent to the Office of the Inspector General for possible civil monetary penalty or exclusion sanction as outlined in Part 9 of the QIO Manual.
BFCC-QIOs are required to conduct quality reviews when complaints about Medicare beneficiaries' healthcare are received from sources other than the beneficiary. These referrals come from a variety of state and federal agencies and organizations that include, but are not limited to:
- the Office of the Inspector General (OIG);
- the Federal Bureau of Investigation (FBI);
- the Centers for Health Dispute Resolution (CHDR);
- the Joint Commission; and
- Medicare Administrative Contractors (MAC).