related links

• Overview
• Appeals
• Beneficiary Complaints
• Medical Record Electronic Submission
• Educational Resources
• Physician Acknowledgement Monitoring
• QIO Liaison
• Memorandum of Agreement
• Update Your Contact Information
• Become a Peer Reviewer
• Case Status Check

overview

Kepro is responsible for other mandatory reviews as part of its a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) contract with the Centers for Medicare & Medicaid Services (CMS).

These other reviews include 

• EMTALA reviews
• Referral reviews 
• Assistant at Cataract reviews

emtala

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 Labor Act (EMTALA) violation case as specified in Part 9 of the QIO Manual (Attachment J-4). The regional office may use this review as a resource in making a compliance determination, rather than simply determining the merits of the complaint.

CMS has released a new training video and infographic that provide a general overview of EMTALA requirements and information on how to file a complaint against a provider or supplier if an individual feels EMTALA has been violated.

For further information on EMTALA, visit CMS’ Quality, Safety and Education Portal (QSEP) at qsep.cms.gov.

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.

referral reviews

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:

• CMS;
• 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).