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Medical Director's Corner - Ferdinand Richards III, MD
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One of the roles and responsibilities of the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) is to accept referrals from other Centers for Medicare & Medicaid Services (CMS) contractors. One contractor that sends referrals frequently is the Zone Program Integrity Contractor (ZPIC). The role of the ZPIC is to prevent, detect, and deter Medicare fraud. During an investigation, the ZPIC may uncover potential quality of care issues that need to be addressed by the BFCC-QIO.
There are seven ZPIC zones, which cover the United States, American Samoa, Guam, the Mariana Islands, Puerto Rico, and the Virgin Islands. The ZPICs can look across the spectrum of providers and practitioners. Once the case is referred to the BFCC-QIO, it is performed as a general quality review. That means that the provider/practitioner only has an opportunity for a reconsideration if a possible quality of care concern is found. It also means that there is no disclosure to the beneficiary or family regarding the findings.
Several ZPIC cases have also become potential sanction cases. That means that two of three Peer Reviewers determined that there was either a gross and flagrant violation or that there were a substantial number of violations. The provider/practitioner is then offered the opportunity for a panel discussion before a corrective action plan (CAP) is recommended. The provider/practitioner may then be placed on a CAP for further monitoring, if the violation is then determined to be either gross and flagrant or substantial number of violations. If the CAP is not completed or not completed to the satisfaction of the BFCC-QIO, the BFCC-QIO can recommend to the Office of the Inspector General (OIG) that a provider/practitioner be sanctioned.
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Q. If a beneficiary was admitted to a hospital and at one point in time was considered inpatient but is  later moved to observation status prior to being discharged, would he/she still be able to have a discharge appeal conducted by the BFCC-QIO?
A. If a patient is in observation (even if the status was changed), they have no appeal rights through the BFCC-QIO. Beneficiaries can appeal through the standard appeal process conducted by the Medicare Administrative Contractors (MAC).
Clarification from the last issue:
Q. What if the beneficiary did not fully read their discharge notice and has already been discharged from the facility? What options would there be? Is Immediate Advocacy the only option, or is there any way to do an appeal after they have already left the facility?
A. If a beneficiary felt that the discharge was not appropriate, he/she could file a quality of care complaint about a premature discharge. Beneficiaries cannot appeal to stay longer after they have left the facility. They can only file an appeal related to financial liability after discharge.
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During the following dates, we want to make you aware that KEPRO will be unable to verify Medicare coverage as well as enrollment in a Medicare Advantage plan, due to scheduled CMS monthly system maintenance. During this time, KEPRO will attempt to function as normally as possible by providing our usual level of service while assisting Medicare beneficiaries, families, or their designee during the appeal/case review process.
The 2016 monthly system maintenance schedule is below and is subject to change. Maintenance will begin at 8 p.m. ET on the first day and conclude at 6 a.m. ET on the final day.
- February 26-28
- March 11-13 and 16-21
- April 29 - May 1
- May 20-22
- June 24-26
- July 15-17
- August 19-21
- September 16-18
- October 21-23
- November 18-20
- December 16-18
If you have questions relating to this outage, please contact KEPRO via e-mail at [email protected]
or click here
for additional contact information. Thank you for your patience in working with us during this time.
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Immediate Advocacy Success Story
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Immediate Advocacy is an informal process in which the BFCC-QIO acts as a liaison for the Medicare  beneficiary to quickly resolve an oral complaint. Below is an example of a KEPRO Success Story.
A beneficiary's daughter contacted the BFCC-QIO with concerns about her mother's care in the hospital. She was being treated for stomach pain and cramping (possible food poisoning). Her pain medication was causing more stomach pain as well as constipation. She was put on a liquid diet, but the daughter stated that the staff continued to bring food trays. The family was concerned that the mother's condition was deteriorating, and they were not able to get any answers from the hospital staff.
The KEPRO Intake Specialist contacted the Risk Management Director at the hospital, who contacted the Director of Nursing about the situation. The Director of Nursing had been making daily rounds to this patient because of these issues, but the family had not been at the bedside. The patient did have a nasogastric (NG) feeding tube, so she was receiving nutrition. The Risk Management Director also stated that the Director of Nursing would contact the family to set up a conference time to go over the treatment plan and concerns and address any issues with them. The Risk Management Director expressed her appreciation to the Intake Specialist for bringing these issues to her attention with an advocacy effort rather than having the family make a complaint
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Regarding hospital or long-term acute care hospital discharge reviews: if the patient's discharge plan is to a skilled nursing facility (SNF), appropriate discharge planning should include arrangements and verification of available SNF placement (bed). This should be documented in the medical records sent in for the appeals review process. If there isn't a confirmed bed, no review will be conducted, and a new notice will need to be reissued once SNF placement has been verified/confirmed.
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Two-Midnight Short-Stay Reviews Update
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KEPRO has begun requesting medical records for the Two-Midnight Short-Stay Reviews (previously known as the MAC Probe and Educate Reviews). All appropriate providers in KEPRO's Service Areas will receive a request for 10 or 25 cases within each six-month period. These requests will be spread over the six-month period of October 2015 through March 2016. The second six-month cycle will begin shortly thereafter.
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Annual Physician Acknowledgement Statement Monitoring
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Under federal regulations found at 42 CFR 412.46 (one of the conditions at 42 CFR 412, Subpart C), hospitals that are paid under the prospective payment system or PPS are required to obtain a signed acknowledgement statement from all newly credentialed admitting physicians. The federal regulations require the physician to complete this form at the time admitting privileges are granted or before his/her first patient is admitted or before the claim is submitted for payment. When the hospital submits a claim, it must have on file a signed and dated acknowledgement from the attending physician that the physician has received the notice specified in 42 CFR 412.46(b).
KEPRO has recently completed the monitoring for calendar year 2014. Two thousand six hundred and ninety (2690) hospitals were monitored for compliance to this regulation. Forty (40) hospitals were noted with deficiencies. These deficiencies included: 
- Hospital failed to submit a roster of all credentialed physicians for 2014; or
- Hospital failed to submit requested statements for validation; or
- Hospital submitted a claim prior to the signature date of the physician statement.
Monitoring for calendar year 2015 has begun. To ensure that your facility meets these regulations, please notify KEPRO of any key personnel changes as quickly as possible.
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The CMS esMD Portal for medical record submission is now operational for responding to medical record requests for HWDRG cases and for Two-Midnight Short-Stay Review cases. Please use the BFCC-QIO claim key number as the claim ID, and use leading zeros to fill the esMD required field length.
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The BFCC-QIO's Annual Reports have been posted to our website. They contain a wealth of information about KEPRO's review volume and findings. The findings are broken out by state for each of KEPRO's 33 states along with the District of Columbia.
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Peer Reviewer Recruitment - KEPRO is Hiring Peer Reviewers
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KEPRO continues to expand its Peer Reviewer roster for all three contract areas. Opportunities for Peer Reviewers of all health care disciplines such as advanced nursing, various therapies (physical, occupational, speech), and physicians currently exist.
KEPRO Peer Reviewers:
- Are offered challenging opportunities to use their medical knowledge to improve the quality of health care;
- Enjoy competitive compensation;
- Receive complete confidentiality;
- Have the convenience of reviewing a case at home or at the office and in many cases electronically; and
- Can join a pool of colleagues who are leaders in their respective specialties.
For further information, contact Jessica Whitley, MD, Medical Director, at 216-447-9604, extension 5784, or email [email protected]
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Save the Date!
Join us for a BFCC-QIO webinar! We offer information and assistance to providers, patients, and families regarding beneficiary complaints, discharge appeals, and Immediate Advocacy. During the webinar, KEPRO representatives will present an overview of the role of the BFCC-QIO and the services provided.
What: The BFCC-QIO Program
Who: Healthcare providers and stakeholders
When: March 31, 2016, 2 - 3 p.m. ET
Speakers: Lisa Stansbury, Outreach Specialist, KEPRO; Lesa Allen-Gaither,
Outreach Specialist, KEPRO
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Coding Update
Coding and DRG validation reviews are currently being performed using ICD-9 and ICD-10 code sets. The code set used is determined according to the code set used by the provider at the time the claim was first billed.
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