No. 9

Acute Care Edition
Medical Director's Corner - Ferdinand Richards III, MD
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.
QIO Manual Chapter 5 Changes
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.
CMS PFE Engagement Strategy
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.
KEPRO Receives Award for Healthcare Quality Improvement Work
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."

Hospital Discharge Appeals
When a beneficiary is admitted to the hospital as an inpatient, he/she is given an Important Message from Medicare (IM) explaining the right to file an appeal when the hospital attending physician feels that he/she is medically stable to discharge. There are instances however when the hospital may not be able to get the attending physician to write a discharge order, even though the beneficiary no longer medically needs to be in the acute setting, but the physician feels the patient is not safe or ready to discharge.
In this circumstance, the hospital staff may initiate a hospital requested review (HRR or HINN 10) and request that the BFCC-QIO review the beneficiary's medical records, to determine if the acute setting is appropriate or not. If the BFCC-QIO states the patient no longer requires acute care, then discharge planning can move forward, and the beneficiary can be discharged. The beneficiary does have a right to file a second level appeal (reconsideration) if he/she does not agree with the discharge. Just as with a regular discharge appeal, it can take up to three days to get a determination for the reconsideration, and there is no financial liability protection for the beneficiary unless the physician reviewer states the beneficiary is not medically stable for discharge.
Immediate Advocacy Success Story
Immediate Advocacy is an informal process in which KEPRO acts as a liaison for a Medicare beneficiary to quickly resolve an oral complaint. Below is an example of a KEPRO success story.
A Medicare beneficiary's husband contacted KEPRO with concerns about his wife's plan of care and treatment in the hospital. They had tried several times to reach the admitting physician, but they were unable to get a response. The doctor saw her briefly at admission; however, she had not been back since and had not returned their calls. They also tried to go through the nurse to reach the doctor, but she also had not returned their calls. They wanted to know their options for treatment and what palliative decisions they needed to be considering but had not been able to get any direction; therefore, the husband contacted KEPRO.
The KEPRO Intake Specialist contacted the hospital QIO Liaison and advised her of the request for advocacy intervention. The QIO Liaison stated that she would have the Patient Advocate or someone in Case Management speak with the beneficiary and her husband and go over their concerns. She advised that KEPRO would be contacted with the resolution.
The Intake Specialist received a call back from the hospital. The Associate Chief Nursing Officer and the Hospital Administrator had been in to speak with the family. The attending physician was not on call, so the rounding partner spent time with the beneficiary and her husband going over the plan of care. The KEPRO Intake Specialist then left a message for the beneficiary's husband to let him know that the intervention was complete.
Higher Weighted Diagnosis-Related Group (HWDRG) Reviews
KEPRO has been receiving questions about the timing and applicability of FY2017 coding and DRG changes as it relates to HWDRG reviews. Our use and application of coding updates and DRG changes is according to the actual dates of service of the particular case being reviewed. HWDRG cases with discharge dates on or after 10-1-16 are reviewed in accordance with the FY2017 regulatory updates.
Short Stay Reviews
As part of the CMS review guidance for Short Stay Reviews, all medical records submitted for payment under Medicare Part A are required to have a valid inpatient order.
Per CMS guidance and noted in the Hospital Inpatient Admission Order and Certification document on the CMS website, "the order must identify the qualified admitting practitioner and must be authenticated (countersigned) by the ordering practitioner promptly and prior to discharge."
In the event the order has been written by a non-physician practitioner or resident authorized by the state in which the hospital is located to admit patients and are allowed by hospital by-laws or policies to do the same:
Per CMS guidance and noted in the Hospital Inpatient Admission Order and Certification document (linked above): "the ordering practitioner may allow these individuals to write inpatient admission orders on his or her behalf, if the ordering practitioner approves and accepts responsibility for the admission decision by counter-signing the order prior to discharge."
MOON Notice
The Medicare Outpatient Observation Notice (MOON) is a standardized notice to inform beneficiaries (including Medicare health plan enrollees) that they are an outpatient receiving observation services and are not an inpatient of the hospital or critical access hospital (CAH). The MOON must be implemented by your hospital by March 8, 2017, and is available for download on the CMS website.
Acute Care FAQs
Q. Does KEPRO accept appeals when the beneficiary is in the hospital based on the beneficiary not wanting to go to a certain skilled nursing facility?
A. As long as the hospital has an accepting bed, the notice should be given. The patient does have appeal rights in this situation.
Q. When is a patient required to provide written consent versus provide verbal consent by phone? Is there a difference between the consent required for a Quality of Care complaint versus a discharge appeal?
A. When a Quality of Care complaint is filed, the beneficiary must agree in writing to disclose his or her identity. When an appeal is filed, they are providing informed consent by the act of filing the appeal. Written consent is not required.
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 30, 2017, 2 p.m. - 3 p.m. ET
Speakers: Lesa Allen-Gaither, Outreach Specialist, KEPRO; Shiva Mumtazi, Outreach Specialist, KEPRO
Publication No. A234-435-2/2017. 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.