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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
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).
short stay and higher weighted diagnosis-related group reviews
In 2019, CMS decided that short stay reviews and higher weighted diagnosis-related group (HWDRG) reviews would no longer be performed by regional BFCC-QIOs. Instead, CMS would award this work to a single national contractor.
Livanta will conduct this work on a national scale, including all 50 states, five U.S. territories, and Washington, D.C.
For more information about short stay and HWDRG reviews or for Livanta’s contact information, please visit Livanta’s website, www.livantaqio.com.