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Medical Director's Corner - Ferdinand Richards III, MD
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One of the responsibilities of the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) is to take Quality of Care complaints from Medicare beneficiaries or their representatives. The formal complaint process involves a medical record review. However, not all complaints are suitable for this type of review. To assist with these other types of complaints, there is another less formal process, which is referred to as Immediate Advocacy (IA).
The IA process allows the BFCC-QIO to act as a mediator between the beneficiary/representative and the provider or practitioner. The beneficiary or representative calls the BFCC-QIO with a concern. The Intake Specialist at the BFCC-QIO recommends the IA process, if it is appropriate. The beneficiary or representative must then give permission for the Intake Specialist to contact the provider or practitioner on his/her behalf. This is a voluntary process, so the provider or practitioner must also agree to participate. IA typically involves a phone call and hopefully resolution within a day or so. Below is an example of an IA Success Story.
A Medicare beneficiary contacted KEPRO with concerns that his insurance plan was not providing coverage for a needed eye exam. The beneficiary had seen his primary care physician (PCP) and explained that his right eye was blurry. The PCP thought he might have a cataract and referred him to an eye doctor for a consultation. The eye doctor's office stated that the insurance would not cover the visit.
The KEPRO Intake Specialist arranged a conference call with the beneficiary and the insurance provider's representative. The representative stated that the eye doctor that the beneficiary contacted was not a preferred provider. She provided the beneficiary with the name of another provider and also contacted that provider, to ensure that the office accepted the beneficiary's insurance plan. After the beneficiary received the new provider's information, he stated that he would get a new referral from his PCP's office. The beneficiary was pleased with the intervention by the BFCC-QIO.
Around 30% of complaints that KEPRO receives are resolved through IA. It is a much quicker process, usually with positive outcomes. One of the benefits for providers is that it may resolve an issue before it escalates into a formal beneficiary complaint. For more information about the IA process, please visit our
website.
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QIO Manual Chapter 5 Changes
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The Centers for Medicare & Medicaid Services (CMS) has recently revised Chapter 5 of the Quality Improvement Organization (QIO) Manual, due to revisions to 42 Code of Federal Regulations (CFR) Part 476 (Quality Improvement Organization Utilization and Quality Review) in the final rule published on November 15, 2012 (77 FR 68210, 68508 - 68526 and 68559 - 68563). In this revised chapter are changes to the Quality of Care review process effective February 1, 2017:
- Providers will now have 14 calendar days (they were previously allowed 30 days) to send in the medical record when a Quality of Care complaint is filed. Because of these tightened time frames, we encourage providers to fax medical records to KEPRO rather than sending them via mail. The Quality of Care department at KEPRO has its own dedicated fax number, which will be listed on the medical record request.
- After the medical records are received, KEPRO has 30 days to complete the review. Providers that wish to provide a response when they receive an inquiry from KEPRO will also have a shortened time frame, which will be noted on the inquiry letter.
- Medicare beneficiaries, or their representatives, will have the opportunity to request a second review if they disagree with the original findings, similar to the current process in place for providers.
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CMS PFE Engagement Strategy
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In December 2016, CMS released their strategy for Person and Family Engagement (PFE). CMS views PFE as "
patients and families being part of the health care team by working collaboratively with their doctor or other health care professional to be active partners when making decisions about their health."
The CMS PFE Strategy will serve as a guide for the implementation of PFE principles and strategies throughout CMS programs.
For more information, go to
CMS PFE Strategy.
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KEPRO Receives Award for Healthcare Quality Improvement Work
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In December 2016, KEPRO received an award from CMS for its health care quality improvement work and unprecedented impact on patient safety in hospitals across the United States. Because of the collaborative work done by KEPRO and other partners, 87,000 lives have been saved, 2.1 million fewer patient harms have occurred, and there has been a cost savings of $19.8 billion. "We're honored to receive this award," stated Gayle Smith, Vice President of Federal Programs. "But this award goes beyond KEPRO. It honors all of those that we work with - providers, partners, and Medicare beneficiaries. Together, we are improving the Quality of Care throughout the country."
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Valid Notice of Medicare Non-Coverage
Both Medicare beneficiaries and providers have certain rights and protections related to financial liability under the Fee-for-Service (FFS) Medicare and the Medicare Advantage (MA) programs. These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers, such as the Notice of Medicare Non-Coverage (NOMNC). Home health agencies, skilled nursing facilities, hospices, and comprehensive outpatient rehabilitation facilities are required to provide a NOMNC to beneficiaries when their Medicare covered service(s) are ending. The NOMNC informs beneficiaries how to request an expedited determination from their BFCC-QIO and gives beneficiaries the opportunity to request an expedited determination. A Detailed Explanation of Non-Coverage (DENC) is given only if a beneficiary requests an expedited determination. The DENC explains/provides the specific reasons for the termination of skilled services.
As part of the BFCC-QIO's review process, it must first determine the validity of the NOMNC that has been issued prior to conducting a review. KEPRO reviews the issued NOMNC to determine if it:
- Is less than two (2 ) pages in length
- Contains the correct OMB approval number (0938-0953)
- Uses the correct CMS form number - Form CMS 10123-NOMNC (Approved 12/31/2011)
- Includes the patient's name
- Includes a patient's identification/medical record number (this cannot be the patient's Social Security or Health Insurance Claim Number)
- Has an Effective Date present
- Includes the correct KEPRO telephone number for the Area in which services are provided (Area 2, Area 3, or Area 4 toll-free number to be listed)
- Includes a beneficiary or representative signature present (to demonstrate their receipt and understanding of the notice)
a. If there is no signature noted on the NOMNC, is there documentation that the beneficiary or their representative "refused" to sign the Notice?
- Shows two (2) days between signature date and Effective Date
Telephonic Delivery of the Notice of Medicare Non-Coverage
Providers may deliver the NOMNC to representatives whom the beneficiary has authorized and appointed to act on his/her behalf during the appeal process. This designation can be through the use of legal documents, such as Power of Attorney, Healthcare Surrogate, or the use of
CMS form
, CMS-1696 "Appointment of Representative." When notifying the representative, the provider should inform him/her of the beneficiary's right to appeal a coverage termination decision and include the following information:
- Beneficiary's last day of covered services and the date when the beneficiary's liability is expected to begin
- Beneficiary's right to appeal a coverage termination decision
- A description of how to request an appeal by a BFCC-QIO
- The deadline to request a review as well as what to do if the deadline is missed
- The telephone number of the BFCC-QIO to request the appeal
If the provider chooses to contact the representative by telephone, the date the information is communicated is considered the NOMNC's receipt date. The provider should annotate the NOMNC to document the telephone contact with the beneficiary and/or representative on the day that the provider made telephone contact, reflecting that all of the information indicated above was included in the communication. The annotated NOMNC should also include the name of the staff person initiating the contact, the name of the representative contacted by telephone, the date/time of the telephone contact, and the telephone number called. The provider must place a dated copy of the annotated NOMNC in the beneficiary's medical file and mail a NOMNC to the representative the day the telephone contact is made. KEPRO has a
notice
on the website that gives sample language with all of the elements that need to be covered during the conversation.
KEPRO will invalidate NOMNCs that have an Effective Date greater than four days in the future. For example, if KEPRO receives a NOMNC with an Effective Date that is more than four days from the appeal request, this NOMNC will be made invalid.
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Immediate Advocacy Success Story
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Immediate Advocacy is an informal process in which KEPRO acts as a liaison for the Medicare beneficiary to quickly resolve an oral complaint. Below is an example of a KEPRO success story.
A Medicare beneficiary's sister contacted KEPRO with concerns about her sister's home health services. The beneficiary had been discharged from a hospital to a skilled nursing facility and then home, where she was to have home health services. However, the home health agency stated that they were still awaiting approval from the MA plan. The beneficiary had been without services for close to two months.
The KEPRO Intake Specialist contacted the scheduling coordinator at the home health agency. She  stated that the agency did receive the referral, but they had not been successful in getting further authorization from the insurance company. Nursing, physical therapy, and occupational therapy evaluations had been completed, but they were waiting for further authorization in order to start the visits. The KEPRO Intake Specialist then contacted the insurance company, and the representative stated that it was noted in the system that evaluations and three additional visits had been approved. The KEPRO Intake Specialist explained that there must have been some miscommunication and that the beneficiary had been left with no care.
The KEPRO Intake Specialist then completed a conference call with the home health agency representative and the insurance company representative. After that meeting, the home health agency representative stated that she would be making arrangements to schedule another visit for the beneficiary. The KEPRO Intake Specialist followed up with the beneficiary's sister and was able to get a therapy visit scheduled. The beneficiary's sister appreciated the assistance provided by KEPRO.
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Q. What is the step-by-step process for filing an appeal regarding the discontinuation of skilled services?
A. Once the initial call has been received, the provider is notified of the appeal request, and the medical records are requested. Once they are received, a nurse will prepare them for a peer reviewer. The physician will determine if continued skilled services are needed, and the beneficiary and provider will be notified. This whole process must be completed within 72 hours from the initial call for skilled services appeals. A reconsideration can be requested by the beneficiary or his/her representative, if the determination does not go in his/her favor.
Q. If a facility gives the discharge notice to an incompetent patient and does not contact the caregiver/guardian, is there any recourse?
A. If the BFCC-QIO is made aware of this, the discharge notice will be declared invalid, and the facility will need to issue it to the caregiver/guardian.
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SAVE THE DATE!
Join
us for a BFCC-QIO webinar! We offer information and assistance to providers, patients, and families regarding beneficiary complaints, discharge appeals, and Immediate Advocacy. During the webinar, KEPRO representatives will present an overview of the role of the BFCC-QIO and the services provided.
What: The BFCC-QIO Program
Who: Healthcare providers and stakeholders
When: March 20, 2017, 2 p.m. - 3 p.m. ET
Speakers: Lesa Allen-Gaither, Outreach Specialist, KEPRO; Shiva Mumtazi, Outreach Specialist, KEPRO
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