SUMMER
2017
ISSUE
No. 11

CASE REVIEW CONNECTIONS
Acute Care Edition
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Medical Director's Corner - Ferdinand Richards III, MD
The Centers for Medicare & Medicaid Services (CMS) has released its annual Quality Improvement Organization (QIO) Program Progress Report for 2016, which provides updates on the activities of the QIO Program. In this report are the accomplishments of both the Beneficiary and Family Centered Care QIOs (BFCC-QIOs) and the Quality Innovation Network QIOs (QIN-QIOs).
 
During 2016, the BFCC-QIOs completed more than 448,200 reviews and saved the Medicare program $20 million processing Higher Weighted Diagnosis-Related Group (HWDRG) reviews. More than 328,800 discharge appeal reviews were completed, resulting in 68,200 beneficiaries not being discharged when they needed continued care. Appeal types include skilled nursing facilities, acute rehabilitation, hospital, and hospice discharges as well as admission denials. BFCC-QIOs performed more than 29,050 quality of care reviews, which identified opportunities for quality improvement in various settings. Then the BFCC-QIOs partnered with the QIN-QIOs to implement more than 730 quality improvement initiatives to address the identified concerns.
 
QIN-QIOs were successful in achieving meaningful results in the areas of care coordination, diabetes care, and nursing home care. CMS leaders were awarded the Samuel J. Heyman Service to America Medal (SAMMIE) as Federal Employees of the Year for achieving major improvements in hospital patient safety in collaboration with diverse public-private sector partners such as QIOs.

Learn more about the impact of the QIO Program in your state.
Bar Codes on Medical Records for Appeals
Reminder: KEPRO has added a bar code to all appeal medical record fax requests sent to healthcare providers and Medicare Advantage health plans. These bar codes directly correlate to the case ID associated with each appeal. KEPRO kindly requests that all providers include the fax request document with this bar code when submitting medical records to KEPRO. If there are multiple medical records or batches of records, please include the fax request document with the bar code as the first sheet of each batch.
Renewal of Important Message from Medicare and Detailed Notice of Discharge Forms
On June 7, 2017, CMS posted new versions of the Important Message from Medicare (IM) form (CMS-R-193) and the Detailed Notice of Discharge (DND) form (CMS 10066) on the Hospital Discharge Appeal Notices page of the Beneficiary Notices Initiative website. The associated instructions for use are also available.

The new IM form incorporates the following language related to discrimination - "For more information, call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048. CMS does not discriminate in its programs and activities. To request this publication
in an alternate format, please call: 1-800-MEDICARE or email:   AltFormatRequest@cms.hhs.gov ." The DND also has new language related to discrimination. Both forms have new expiration dates. If you have questions regarding the IM and DND, please e-mail BNImailbox@cms.hhs.gov.

CMS is requiring that the new version of these forms must be in use by August 28, 2017.
Person and Family Engagement
Person and Family Engagement is one of CMS' key initiatives. It emphasizes the importance of patient engagement and patient's voices. Would you be interested in a free webinar for your organization about Person and Family Engagement? If so, please click here for more information.
Immediate Advocacy Success Story
Immediate Advocacy is an informal process in which KEPRO acts as a liaison for a Medicare beneficiary or his or her representative to quickly resolve a verbal complaint. Below is an example of a KEPRO success story.

A Medicare beneficiary's representative contacted KEPRO with concerns about his mother's care at the hospital. She went into the hospital with a seizure and was given medication. The son was concerned because his mother was experiencing additional seizures and stroke symptoms, and he thought she could have been given an inappropriate medication. He called KEPRO for assistance.
 
A KEPRO Intake Specialist contacted the QIO Liaison at the hospital and spoke to the Patient Advocate from the facility. The Patient Advocate explained that the staff was aware of the family's concerns. A meeting was set up with multiple disciplines, to help the family understand more about the plan of care. The patient was also being transferred to a different level of care, so she could undergo neurological monitoring.
 
The KEPRO Intake Specialist followed up with the son after the meeting had occurred. He shared that a second meeting had taken place, the situation was much better, and he was happy with the outcome. He thanked the KEPRO Intake Specialist for her assistance.
Higher Weighted Diagnosis-Related Group (HWDRG) Reviews
Did you know that there is a central virtual voicemail line for healthcare providers with questions about HWDRG reviews? Call the Beneficiary Helpline in your Area and use Extension 7475 to get assistance with HWDRG-related provider or status questions. This applies to all three KEPRO Areas.
Additionally, HWDRG status requests can be faxed to 844-403-3948 for all three KEPRO Areas.
Short Stay Reviews
KEPRO has implemented an online program that will allow hospital providers to schedule a Short Stay review educational session when they receive an initial determination letter with a Major Concern. This program can be accessed on the KEPRO website and should improve ease of scheduling for these sessions. This should also enhance the timeliness of the educational sessions. We hope that hospital providers will find convenience with the new online scheduling program and take advantage of this opportunity. If you have further questions about Short Stay reviews or the online scheduling program, please contact 813-280-8256 ext. 7480 or KEPROteleconference.resource@hcqis.org.
Acute Care FAQs
Q. With Short Stay reviews, what is the time frame for providers to give a final determination after an educational session? 
 
A. The provider has 10 days post teleconference to submit additional documentation, so KEPRO waits more than 10 days before creating a final results letter. 
 
Q. Once the Short Stay review final letter is sent, can the provider appeal after KEPRO's final determination? 

A. Providers can appeal to the Medicare Administrative Contractor (MAC) after the final determination.
5 Ways for Healthcare Providers to Get Ready for New Medicare Cards
Medicare is taking steps to remove Social Security numbers from Medicare cards. Through this initiative, CMS will prevent fraud, fight identity theft, and protect essential program funding and the private healthcare and financial information of our Medicare beneficiaries.  

CMS will issue new Medicare cards with a new unique, randomly-assigned number called a Medicare Beneficiary Identifier (MBI) to replace the existing Social Security-based Health Insurance Claim Number (HICN) both on the cards and in various CMS systems they use now. CMS will start mailing new cards to people with Medicare benefits in April 2018. All Medicare cards will be replaced by April 2019.

CMS is committed to helping providers by giving them the tools they need. They want to make this process as easy as possible for patients and staff. Based on feedback from healthcare providers, practice managers, and other stakeholders, CMS is developing capabilities where doctors and other healthcare providers will be able to look up the new MBI through a secure tool at the point of service. To make this change easier, there is a 21-month transition period where all healthcare providers will be able to use either the MBI or the HICN for billing purposes. 

SAVE THE DATE!
 
Join us for a BFCC-QIO webinar! We offer three services to Medicare beneficiaries and their families: beneficiary complaints, discharge appeals, and Immediate Advocacy. This webinar will present a basic overview of these services as well as an introduction to some provider-based services.
  
What: The BFCC-QIO Program
Who: Healthcare providers and stakeholders
When: September 20, 2017, 2 p.m. - 3 p.m. ET
Speakers: Lucia Di Gioia, Outreach Specialist, KEPRO; Lesa Allen-Gaither, Outreach Specialist, KEPRO
 
 
Publication No. A234-521-8/2017. 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.
Please do not copy/paste information from Case Review Connections. If you'd like to communicate BFCC-QIO information, please contact KEPRO at KEPRO.Communications@hcqis.org.