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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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This is clarification regarding issuance of the Notice of Medicare Non-Coverage (NOMNC).
- Patients who are traditional Medicare need to be aware that Medicare allows the BFCC-QIO up to two (2) days past the last covered day to render a decision; this can create potential financial liability for the Medicare beneficiary while waiting for a decision to be rendered.
- When issuing the NOMNC to a representative, CMS has provided the healthcare community with directions for proper documentation of such an event. Providers should include the following information in your communications:
- The beneficiary's last day of covered services and the date when the beneficiary's liability is expected to begin;
- The beneficiary's right to appeal a coverage termination decision;
- A description of how to request an appeal by a BFCC-QIO;
- The deadline to request a review as well as what to do if the deadline is missed; and
- The telephone number of the BFCC-QIO to request the appeal.
If you choose to contact the representative by telephone, the date you communicate the information is considered the NOMNC's receipt date. You should annotate the NOMNC to document the telephone contact with the beneficiary on the day that you make telephone contact, reflecting that all of the information indicated above was included in the communication. The annotated NOMNC should also include the name of the staff person initiating the contact, the name of the representative contacted by phone, the date and time of the telephone contact, and the telephone number called. Otherwise, the NOMNC may be deemed INVALID in order to protect the Medicare beneficiary's financial liability.
You must place a dated copy of the annotated NOMNC in the beneficiary's medical file and mail a NOMNC to the representative the day the telephone contact is made.
Source: MLN Matters ® Number: MM7903
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CMS System Maintenance Schedule
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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 CMS 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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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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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 Medicare beneficiary contacted the BFCC-QIO with concerns about her occupational therapy provided by a home health agency. She felt that the equipment that was being used in her therapy was not effective. When she attempted to convey her concerns to the staff, she was told that she could buy her own equipment. She felt that the therapist should provide the appropriate equipment.
The KEPRO Intake Specialist contacted the Administrator of the home health agency. The Administrator noted that there had been several issues with this beneficiary previously, but this was the first time he had heard about concerns with the equipment.
A conference call was scheduled with the beneficiary, the Administrator, and the Intake Specialist. After the call, the Administrator agreed to order equipment that was more appropriate for the beneficiary.
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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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Q. Is the NOMNC the same as the ABN? 
A. No. They are not the same thing. The NOMNC is used in the outpatient setting for termination of services appeals, and the Advance Beneficiary Notice (ABN) is used with outpatients in multiple settings. KEPRO does not process ABN appeals.
Q. How does the Jimmo v. Sebelius ruling affect KEPRO's work?
A. It affects the way the BFCC-QIO handles aspects of a review case. Peer Reviewers are no longer to stop skilled services using the rationale that a patient has "plateaued"; therefore, this wording is no longer used. Peer Reviewers have to provide another rationale.
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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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