KEPRO Beneficiary And Family Centered Care Quality .

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KEPROBeneficiary and Family Centered CareQuality Improvement OrganizationAndrea Plaskett, MPH1

KEPRO KEPRO is a federal contractor for the Centersfor Medicare & Medicaid Services (CMS) KEPRO is the Beneficiary and Family CenteredCare Quality Improvement Organization(BFCC-QIO) in CMS Areas 2, 3, and 4 Each state also has a Quality InnovationNetwork Quality Improvement Organization(QIN-QIO), which can be found Livanta is the BFCC-QIO for CMS Areas 1 and 52

KEPRO’s Service AreasArea 2Delaware, District of Columbia, Florida, Georgia,Maryland, North Carolina, South Carolina,Virginia, and West VirginiaArea 3Alabama, Arkansas, Colorado, Kentucky,Louisiana, Mississippi, Montana, New Mexico,North Dakota, Oklahoma, South Dakota,Tennessee, Texas, Utah, and WyomingArea 4Illinois, Indiana, Iowa, Kansas, Michigan,Minnesota, Missouri, Nebraska, Ohio, andWisconsin3

KEPRO’s Services forMedicare Beneficiaries Discharge Appeals andService Terminations Beneficiary Complaints Immediate Advocacy (IA)KEPRO’s services are alsoavailable for MedicareAdvantage beneficiariesand beneficiaries withMedicare as a secondary4

Appeals Acute Care – Discharge Appeals– Important Message from Medicare (revised 2017)– Preadmission/Admission Hospital Issued Noticeof Non-coverage (HINN)– Hospital RequestedReview (HRR) Post-Acute Care – ServiceTerminations– Notice of MedicareNon-coverage5

Appeals ProcessOverviewThe provider issues the notice.The beneficiary or representativecalls for an appeal.KEPRO requests the record.The record is reviewed by theKEPRO physician.The beneficiary and provider (and plan ifnecessary) are notified of the decision.6

Appeals Financial liability Time frames Observation status Appeal statusupdateswww.keproqio.com7

Example of an AppealI live in another city, but when my grandmotherfell and broke her hip, I got some time off work tovisit her. She can barely get out of bed to walk.Now the hospital says they are discharging her,and I have to go back home. She lives alone, andI don’t think she is ready to be discharged.8

Beneficiary Complaints Must be about quality of care (medicalrecord review)– Examples include wrong diagnosis andwrong treatment Care must have occurred within the lastthree years and be covered under Medicare Important aspects about the process– Encouraged to complete a CMS complaint form– Must be filed by a Medicare beneficiary or his orher representative– Findings not admissible in a lawsuit9

Quality of Care Reviews:Time Frames Providers now have 14 calendar days (insteadof 30) to send in the medical record when a qualityof care complaint is filed Providers that wish to respond to an inquiry fromKEPRO will also have a shortened time frame, whichwill be noted on the inquiry letter After the medical records are received, KEPRO has30 days to complete the review Due to these shortened time frames, we encourageproviders to fax medical records to KEPRO ratherthan sending them via mail Additional information and education is available

Quality of Care Reviews:Reconsiderations In the past, providers have been able torequest a reconsideration during thereview process Beneficiaries received a final letter with noopportunity for a second review CMS has now provided an opportunity for abeneficiary to request a second review with adifferent physician reviewer if he/she doesnot agree with the review findings Effective February 1, 201711

Beneficiary ComplaintsProcess OverviewComplaint form issubmitted to KEPRONurse contacts thebeneficiary orrepresentative todiscuss the concernsNurse prepares thecase for thePhysician ReviewerPhysician Reviewerdetermines whetherthe care metprofessionallyrecognized standardsof careCare that does notmeet standards isreferred to the QINQIO for a QualityImprovementPlan (QIP)A final letter is sent tothe beneficiary orrepresentative with anopportunity for areconsideration12

Example of a Qualityof Care ComplaintMy wife has dementia and is using a wheelchairafter being hospitalized with pneumonia. She isvery weak and is taking several medicines thataffect her walking and standing. They said shefell over in her wheelchair and hit her head. Ithink they should have had someone watchingher or done something to prevent her fall, butthey didn’t seem concerned.A final letter is sent tothe beneficiary orrepresentative with anopportunity for areconsideration13

Immediate Advocacy Informal process used by the BFCC-QIO toresolve a complaint quickly. Process begins when the Medicare beneficiaryor representative gives verbal consent toproceed with the complaint. Once the beneficiary or representative agreesto the process and gives consent, the BFCCQIO contacts the provider or practitioner onbehalf of the beneficiary.14

IA Success StoriesA Medicare beneficiary’s mother contacted the BFCC-QIO withconcerns about her son’s care at the hospital. He was hospitalizedwith brain cancer and had a very poor prognosis. He will need veryintense care upon discharge, and the mother was concerned thatshe would not be able to care for him. The hospital staff wastelling her that he would be sent home with home health, and shefelt overwhelmed and anxious. She requested intervention by theBFCC-QIO.The Intake Specialist left a message for the QIO Liaison regardingthe mother’s concerns. The QIO Liaison returned the call andexplained that she had spoken with Case Management and theyboth agreed that the mother had valid concerns, and they did notwant to send the beneficiary home if that is not in his best interest.The Intake Specialist later received a call from the beneficiary’smother who explained that Case Management is now looking forplacement for her son in a facility.15

IA Success StoriesA Medicare beneficiary contacted the BFCC-QIO with concerns thathis insurance plan was not providing coverage for a needed eyeexam. The beneficiary had seen his primary care physician (PCP)and explained that his right eye was blurry. The PCP thought hemight have a cataract and referred him to an eye doctor for aconsultation. The eye doctor’s office stated that the insurancewould not cover the visit.The Intake Specialist arranged a conference call with thebeneficiary and the insurance provider’s representative. Therepresentative stated that the eye doctor that he contacted was nota preferred provider. She provided the beneficiary with the name ofanother provider and also contacted that provider to ensure thatthe office took the plan. After the beneficiary received the newprovider’s information, he stated that he would get a new referralfrom his PCP’s office. The beneficiary was pleased with theintervention by the BFCC-QIO.16

Short Stay Reviews Short Stay reviews previously performed by theMedicare Administrative Contractors (MACs) foracute care hospitals are now done by BFCC-QIOs– Short Stay reviews focus on educating doctors and hospitalsabout the Part A payment policy for inpatient admissions– CMS randomly samples the top 175 providers with a highor increasing number of Short Stay claims per Area and allother providers previously identified as having “MajorConcerns” in the prior round of review– The provider has up to 45 days to send the medicalrecord. Once the medical record is received, KEPRO has 45days to complete the review– Providers that participate in esMD are able to providemedical records through the portal

Person and FamilyEngagement (PFE)PHILOSOPHYPersonCentered CareOUTCOMEPatientExperienceAPPROACHPerson andFamilyEngagement A collaborative, proactivecommunication andpartnered decision makingbetween healthcareproviders, beneficiaries,and families Why?– Help reduce readmissions– Make care safer– Improve care transitions18

KEPRO’s Role in PFE One of two Beneficiary and Family CenteredCare Quality Improvement Organizations(BFCC-QIOs) Educate beneficiaries, families, providers, andstakeholders on the QIO process andprograms, including Immediate Advocacy andPatient Navigation Overall goal – beneficiaries, families, andcaregivers will have a better understanding ofthe QIO’s role and their health needs, so thatthey are better prepared when talking tomedical professionals19

PFE spect How will KEPRO assist beneficiariesand families?– Immediate Advocacy– Patient Navigation– Review Process Clarification20 Center Immediate Advocacy Patient Navigation21

PFE Projects Project 1 – Always EventsProject 2 – Immediate AdvocacyProject 3 – Provider PartnershipProject 4 – QIN-QIO CollaborationProject 5 – Promoting Beneficiary EngagementProject 6 – Patient Navigation23

KEPRO Availability KEPRO appeals staffwork (local time):– Weekdays: 9 am - 5 pm– Weekends: 11 am - 3 pm– Holidays: 11 am - 3 pm Voicemails may be leftduring all other hours Translation servicesare available24

KEPRO’s Phone Numbersand Additional Resources** Beneficiaries calling for Immediate Advocacy should choose option 1 on the firstprompt followed by option 2 to be connected to the beneficiary complaint department.25

Collaborationwith KEPRO Newsletters Joint presentations– State Health Insurance Assistance Programs (SHIPs)– Medicare Administrative Contractors (Part A, B, and D)– QIN-QIOs Advisory boards– Senior Advisory Councils and Councils on Aging– Health Care Commission and Community QualityImprovement Boards– Reducing Avoidable Readmission Coalitions– State Offices of Elderly Affairs Website26

Summary KEPRO provides services for beneficiaries:––––Discharge appealsBeneficiary complaintsImmediate AdvocacyPatient Navigation KEPRO’s services are free for Medicarebeneficiaries and their representatives More information can be found To subscribe to KEPRO’s newsletter,

References t-andfamily-engagement.html .pdf28

Andrea Plaskett, MPH216.396.7534 (Cell)Andrea.Plaskett@bfcc2.hcqis.orgYour feedback on today’s presentation isappreciated: information presented by KEPRO is conditionally effectivethrough August 2019. However, the Centers for Medicare &Medicaid Services can adjust time frames and guidelines asnecessary. For the most up-to-date information, please visit ourwebsite at

QuestionsPublication No. A234-542-10/2017. This material was prepared by KEPRO, a Medicare Quality Improvement Organization undercontract 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.30

2 KEPRO is a federal contractor for the Centers for Medicare & Medicaid Services (CMS) KEPRO is the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) in CMS Areas 2, 3, and 4 Each state also has a Quality Innovation Network Quality Improvement Organization

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