No. 8

Acute Care Edition
Medical Director's Corner - Ferdinand Richards III, MD
One of the requirements for the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) is to produce an Annual Report for the Centers for Medicare & Medicaid Services (CMS). This report must be available to the public, so that they are able to see the volume and outcome of KEPRO's review activity. I would like to share with you some of the information that is available in these reports.
Each of KEPRO's three areas must prepare an Annual Report; therefore, KEPRO has three reports available. The first section of the report has global data with an appendix that contains data for each state in that area. The report contains information about the total volume of reviews, the top 10 diagnoses for claims in that area, the provider settings associated with beneficiary complaints, the category of quality of care concerns identified during medical record reviews along with the corresponding outcome, and information about the outcomes of discharge appeals.
KEPRO also shares information about the standards of care that are used to make decisions in beneficiary complaints, appeals, and medical necessity reviews. When a medical record review is not required, KEPRO may use a process called Immediate Advocacy to intervene on the behalf of a beneficiary. The report states the number of concerns that have been resolved through the process of Immediate Advocacy. The report also provides the volume of telephone calls that are received and processed by KEPRO. I hope that this information will provide a more complete picture of KEPRO's work, as we strive to improve the quality, safety, and value of care that the Medicare beneficiary receives.
Hospital Discharge Appeals
Courtesy Reminders
Hospitals are required to deliver the Important Message from Medicare (IM), CMS-R-193, to all Medicare beneficiaries (Original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospital inpatients. The IM informs hospitalized inpatient beneficiaries of their hospital discharge appeal rights. Beneficiaries who choose to appeal a discharge decision must receive the Detailed Notice of Discharge (DND) from the hospital or their Medicare Advantage plan, if applicable. These requirements were published in a final rule, CMS-4105-F: Notification of Hospital Discharge Appeal Rights , which became effective on July 1, 2007.
KEPRO will notify the hospital provider of the beneficiary's
request for appeal and will request that medical information be
sent for review. Under federal rules and regulations, the provider
is required to submit the medical information by noon on the day following notification by KEPRO. Since August 2014, KEPRO has utilized a follow-up call or fax transmission as a reminder to providers when requested medical information, associated with appeals, has not been received. Effective December 12, 2016, KEPRO will no longer provide this courtesy reminder.
Hospital Discharge Appeal Process
Hospital discharge appeal requests are made when a beneficiary/representative calls KEPRO after a discharge order has been written by the attending physician stating that the beneficiary no longer requires acute level care. At this point, an IM is given to the beneficiary/representative, and appeal rights are explained. The beneficiary/representative has until midnight on the day the discharge order was written to file a timely request to KEPRO for additional covered time in the hospital or acute setting. A beneficiary may discharge at any point in the appeals process, and KEPRO would still proceed with the appeal review to ensure liability protection. A beneficiary also may appeal the discharge up to 30 days after being discharged from the hospital, to prevent financial liability. In order for the appeal to be processed, the hospital must provide documentation of a safe discharge plan for the beneficiary; if this documentation is not provided, the appeal case is closed.

Hospital Immediate Advocacy Success Story

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 contacted KEPRO with concerns about his care at the hospital when his peripherally inserted central catheter (PICC) line pulled out. The hospital did not have anyone to address the situation, so he was placed in observation until the PICC line could be replaced. He had been in the hospital all weekend, requested to leave, and was told he could not leave. He did not feel it was necessary for him to be in the hospital and requested that no charges be billed because there was no one available to address his situation.
The KEPRO Intake Specialist contacted the QIO Liaison at the hospital. The QIO Liaison stated that the beneficiary had every right to be upset, as he should not have been kept in the hospital all weekend. She stated that an on-call person should have been notified, but the hospital staff did not call the right people. She also stated the appropriate processes were not followed, and changes were being made to make sure that this does not happen again. She also advised that the hospital would not bill for his stay.
The KEPRO Intake Specialist then contacted the beneficiary, and he was very appreciative of the intervention on his behalf. He shared that the PICC line had been replaced and that he was being discharged that day.
Higher Weighted Diagnosis-Related Group (HWDRG) Reviews/Short Stay Reviews
As more providers are attaining subscription access to the CMS esMD Portal for submission of medical records, please note the following:
  • KEPRO accepts record submissions via esMD for HWDRG and for Short Stay review record requests.
  • KEPRO has three designated mailboxes established for esMD submission, according to our Service Areas. Find your state's Service Area.
  • Please include the Medical Record Component Cover Sheet (included with our record request) as the first page of the submission.
  • Please include the KEPRO Claim Key # as the identifier for esMD and use preceding zeros as required for esMD field size requirements.
For more information, visit esMD.

KEPRO recently held a webinar to address the new changes to the Short Stay review process. For information, please click here. You may view the webinar, download the slide presentation, and view the FAQ document.

 Acute Care FAQs

Q. What percentage of quality of care case reviews and discharge appeals are performed by physician reviewers located within the same state that the beneficiary received care?
A. KEPRO strives for a 100% rate within each state, but if KEPRO cannot utilize reviewers in the same state that the beneficiary received care, physician reviewers from within the same KEPRO Service Area are used.
Q. What exactly happens to a provider when a case is referred to a Quality Innovation Network
A. The QIN-QIO will assess the referral from KEPRO and determine what their next steps will be.

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Publication No. A234-376-11/2016. 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.