FALL
2016
ISSUE
No. 8

CASE REVIEW
CONNECTIONS
Post-Acute Care Edition
          
Medical Director's Corner - Ferdinand Richards III
 
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.
Post-Acute Appeals
Courtesy Reminders
Home health agencies, skilled nursing facilities, and comprehensive outpatient rehabilitation facilities are required to provide a Notice of Medicare Non-coverage (NOMNC) to Medicare health plan enrollees when their Medicare-covered service(s) are ending. The NOMNC informs enrollees on how to request an expedited determination from KEPRO and gives enrollees 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 the specific reasons for the end of services.
 
KEPRO will notify the provider of the beneficiary's request for appeal and will request medical information be sent for review. Under federal rules and regulations, the provider is required to submit the medical information by close of business on the day that notification is received from 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.
 
Delivering the Notice of Medicare Non-coverage
The NOMNC may be issued in several ways when skilled services are ending. It is recommended that the notice be handed to the beneficiary or representative in person. If this is not feasible, then the notice can be issued or provided in a number of other Medicare-approved methods. The notice can be provided via telephone to a representative as long as all sufficient documentation required by Medicare is annotated on the notice and the beneficiary is informed of the deadline in which to notify KEPRO to make a timely request. Keep in mind the burden of proof lies with the provider, not the beneficiary/representative. The NOMNC can be sent by certified mail, and proof of the certified stamp must be provided with the medical record request. Lastly, the notice can be e-mailed if that is an agreement between both parties (beneficiary/representative and provider) and must not contain any protected health information (PHI).
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 home health services. He had been in the hospital for a stroke and then was transferred to the skilled nursing facility for rehabilitation. Once those services ended, he was discharged home with home health services. The beneficiary did have an initial visit from the home health agency; however, no one had been back for three weeks. He contacted KEPRO and requested an intervention.
 
The KEPRO Intake Specialist contacted the home health agency and spoke with the Director of Patient Services, who stated she would contact physical therapy to find out more information. After contacting them, she returned the call to the Intake Specialist and explained the situation. Physical therapy had been leaving messages to schedule appointments but had not received any calls back. Because the beneficiary was blind, he had not been able to get to the phone. He had told the nurse during the initial evaluation that he just wanted the staff to come over without calling. However, this information had not been conveyed to physical therapy. The KEPRO Intake Specialist later followed up with the beneficiary who confirmed that the director had contacted him, and the problem had been resolved.

 

Post-Acute Care FAQs

Q. What exactly happens to a provider when a case is referred to a Quality Innovation Network (QIN) QIO?
 
A. The QIN-QIO will assess the referral from KEPRO and determine what their next steps will be.
Clarification:
Q. Does a 3-day stay in an inpatient hospice facility count towards skilled facility care? 
A. No. It must be a hospital stay.                   
     
   
      
Publication No. A234-375-11/2016. 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 Serivces. The contents presented do not necessarily reflect CMS policy.