Images not displaying correctly? View as Webpage Volume 4, Issue 41 | September 5, 2023

Highlights of Outreach and Collaborative Efforts of the Beneficiary and Family Centered Care - Quality Improvement Organization (BFCC-QIO)

Look Inside Livanta: A Changing Landscape, Part 1 of 5

Unprecedented Case Review Volumes In previous years, The Livanta Compass has included a special annual series, Look Inside Livanta, to give readers an insider view of Livanta’s operations related to its Medicare services. This series, which is published to coincide with Livanta’s Annual Medical Review Services Reports, allows readers to understand better what goes on behind the scenes at Livanta, in departments such as the mailroom, communications, call center, and other areas. Today’s issue of The Livanta Compass kicks off this year’s Look Inside Livanta series with a brief overview of the annual reports published by Livanta as required for its Medicare Beneficiary and Family-Centered Care - Quality Improvement Organization (BFCC-QIO) contract. Over the last few years, the volume of Livanta’s BFCC-QIO case reviews has reached higher levels month after month—volumes that have never been seen in the history of the QIO Program. This year’s Look Inside Livanta series offers insights into several changes that have led to these unprecedented volumes and broadly impacted the BFCC-QIO Program. The series also explores the many ways Livanta has remained adept at meeting this expanding need while maintaining excellence in performance metrics such as customer satisfaction, timeliness, and other requirements. Today’s Compass also announces the publication of Livanta’s 2022 Annual Medical Services Review Reports. The reports for each of Livanta’s BFCC-QIO regions can be found at the link below. Livanta’s Annual Medical Review Services Reports https://livantaqio.com/en/About/Annual_Report

About the Annual Medical Review Service Reports

The QIO Program, one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries, is an integral part of the U.S. Department of Health and Human Services’ (HHS) National Quality Strategy for providing better care and better health at lower cost. The mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. As part of its contract with the Centers for Medicare & Medicaid Services (CMS), Livanta prepares annual reports outlining its services as the BFCC-QIO, its case volumes, and other relevant data and information. As a BFCC-QIO, Livanta is committed to protecting Medicare beneficiaries’ rights, addressing their concerns, and reviewing appeals and quality complaints in an effective and efficient patient-centered manner. The Annual Medical Review Services Reports include data for case reviews that Livanta conducts on behalf of Medicare beneficiaries. The annual reports underscore Livanta’s commitment to transparency by providing key performance metrics from its contract with CMS. This year’s annual reports provide summaries of case review data and other information about Livanta’s BFCC-QIO services from January 1, 2022, to December 31, 2022 in each of its case review regions. The reports contain state- and territory-specific data and summary case review data for the respective region. Read on to learn about various sections of these critical reports. Data Tables Livanta’s Annual Medical Review Services Reports contain numerous data tables regarding its case volumes. Case data are broken down for each region and state in several ways, including case types, provider settings, and other elements such as diagnoses, geographic locations, age ranges, and similar details. Medicare Policies and Program Guidelines for Appeal Reviews In conducting appeal reviews, Livanta’s review coordinators and physician reviewers refer to Medicare policy manuals and other policy guidelines from the Medicare program to support case review decisions. An appeal is decided in terms of agreeing or disagreeing with the notice received by the beneficiary stating that they are medically stable to be discharged from the hospital or to have Medicare-covered services terminated. Livanta’s physician reviewers use documentation in the beneficiaries’ medical records to make this determination, validating the care against Medicare policies and guidelines. Standards and Clinical Guidelines for Quality of Care Reviews In conducting quality of care reviews, Livanta’s review coordinators and physician reviewers refer to evidence-based clinical guidelines and published standards of care to support case review decisions. A quality of care concern is confirmed by Livanta when the physician reviewer identifies evidence in the patient’s medical record that demonstrates the healthcare provider or practitioner failed to adhere to these professionally accepted standards of care. Immediate Advocacy Success Stories Livanta’s immediate advocacy program effectively resolves real-time concerns that Medicare beneficiaries or their representatives have with their Medicare-covered care or services. The annual reports each include a de-identified example of an immediate advocacy case that illustrates how the program works.  Outreach and Collaboration As a BFCC-QIO, Livanta conducts a significant amount of outreach and education for various stakeholders. In addition to offering custom webinars or virtual education, Livanta’s communication team maintains its QIO website, social media platforms, and a robust publication schedule and oversees the production of the Annual Medical Review Services Reports. The annual reports include extensive descriptions of these outreach activities.

The Lifecycle of Livanta’s Beneficiary Services

Under its current contract, Livanta provides case review and immediate advocacy services to Medicare beneficiaries and families in five CMS regions—a geography that spans 27 states and territories across the U.S. In fact, Livanta’s services account for approximately two-thirds of the national BFCC-QIO case review volume for Medicare. Livanta’s annual reports data shows a volume of about 200,000 hospital discharge and post-acute service termination appeals in 2022 alone—a number that amounted to an average of nearly 550 reviews per day, 365 days a year, including weekends and holidays. (In 2023, Livanta’s internal tracking shows that this never-before-seen volume will be larger still, as the history-making trends of increasing case volumes has continued throughout this past calendar year.) Additionally, Livanta reviewed thousands of formal complaints made by Medicare beneficiaries during the same period. The right to appeal a discharge or service termination and the right to have a professional review of one’s care are part of the system of rights held by Medicare beneficiaries. This protection is extended to all Medicare beneficiaries, whether enrolled in Original Medicare, a Medicare Advantage Plan, or dually eligible for Medicare and Medicaid. Livanta’s skilled team of medical professionals, nurses, and quality improvement specialists work each day to ensure that patients’ rights are being protected.

Appeals for Discharges or Service Terminations Medicare beneficiaries and their family members or advocates may file an appeal for a hospital discharge if the patient does not believe they are well enough to leave or the discharge plan is not adequate or safe. Beneficiaries may also appeal the notice of discontinuation of services from a skilled nursing facility, swing bed provider, home health agency, hospice, or rehabilitation center if they do not agree with the decision to stop skilled care and services. The hospital or facility must provide Medicare beneficiaries with An Important Message from Medicare (IM) or the Notice of Medicare Non-Coverage (NOMNC), and these forms explain how to file an appeal with the BFCC-QIO. To initiate an appeal, the beneficiary or their representative makes a phone call to Livanta’s Medicare Helpline. Livanta immediately requests the medical records from the facility, and an independent board-certified physician conducts a review to determine whether a continued stay or services is appropriate and medically necessary. Beneficiaries (or their representatives) and the healthcare provider may request a reconsideration of an appeal determination. Quality of Care Reviews Beneficiaries and their appointed representatives have the right to file a quality of care complaint about their health care. To initiate a quality of care review, beneficiaries or their representatives make a phone call to Livanta’s Medicare Helpline. Livanta’s review coordinator asks questions to clarify the details of the complaint further and asks for the provider’s name, address, phone number, and the dates of service. Livanta requests the medical record from the facility, and an independent board-certified physician conducts a review to determine if the care provided met currently accepted medical standards of care. Beneficiaries (or their representatives) and the healthcare provider may request a reconsideration of a quality review. Immediate Advocacy Immediate advocacy is a special service to resolve a beneficiary’s real-time concern quickly. Beneficiaries or their representatives can call Livanta’s Medicare Helpline specifically to get help, but immediate advocacy is offered to all callers. With consent from the beneficiary, family member, or advocate, Livanta contacts the provider of services and facilitates a resolution of the concern or problem. Most immediate advocacy cases are resolved within a few days. Should the provider decline to participate in the advocacy process, the beneficiary or representative is informed of their right to file a formal, written complaint. Other Reviews In addition to these services for Medicare patients, Livanta reviews other types of cases, such as Emergency Medical Treatment & Labor Act (EMTALA) violations, Hospital-Issued Notices of Noncoverage (HINN), and other referrals received from a variety of sources. Please visit the Livanta website at https://livantaqio.com/en/Provider/case_types for a complete list and descriptions of Livanta’s case review and advocacy services.

Next Week's Compass

Drop into The Livanta Compass next week for Part 2 of this series. Part 2 begins the discussion of the significant factors that have recently impacted the BFCC-QIO Program, beginning with the COVID-19 pandemic.

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