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Medical Director's Corner - Ferdinand Richards III, MD
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One of the highest volume reviews that KEPRO performs is appeals, which includes hospital discharge appeals and service terminations. These reviews affect a variety of providers, including hospitals, acute rehabilitation facilities, long-term acute care hospitals, critical access hospitals, skilled nursing facilities, home health agencies, hospices, and outpatient rehabilitation facilities. Medicare beneficiaries are given either the Important Message from Medicare (IM) or the Notice of Medicare Non-coverage (NOMNC), and they have the ability to call KEPRO and request that their services continue.
Many providers have questions about the criteria that KEPRO uses to make these decisions. When reviewing cases, KEPRO strives to use Physician Reviewers from the same state in which the beneficiary is receiving medical care. These physicians have been trained by KEPRO on Medicare's guidelines related to continuing care. They also use their professional judgement regarding the safety of a discharge. Some examples of what the physician would look for in a hospital review include medical stability and a safe disposition. Some examples of what a physician would look for in a skilled nursing review when the patient is getting physical therapy include whether the patient has met his/her goals, current functional capacity, and a safe disposition.
If the chart is incomplete or the documentation is poor and the physician cannot determine whether the patient can be safely discharged, he/she will always find in favor of the patient. Decisions by the Physician Reviewers are also reviewed by one of KEPRO's three Medical Directors, to make sure that guidelines are being followed. More information about the volume of reviews and the rate in which facilities are overturned is available in KEPRO's Annual Reports.
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Person and Family Engagement
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 KEPRO is embarking on an exciting new project that will encourage Medicare beneficiaries and their families to be more involved in their health care. The Person and Family Engagement (PFE) projects will reflect
beneficiary
and family perspectives and needs; provide opportunities for
beneficiary
engagement and education; foster improved case review experiences for patients, their families, and clinicians; and encourage
proactive communication and partnered decision-making between healthcare providers and patients, families, and caregivers
. For more information, visit the QIO Program PFE Overview or KEPRO's PFE website page.
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New Process for Medical Records Submitted to KEPRO for Appeals
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As a quality improvement organization, KEPRO is continually evaluating its processes and looking for improvement in efficiencies and its responsiveness to its customers. With that in mind, beginning in summer 2017, KEPRO will implement a new medical record request form to be used for all appeal reviews. KEPRO will add a bar code to all appeal medical record fax requests sent to healthcare providers and Medicare Advantage health plans. These bar codes will directly correlate to the case ID associated with each appeal. KEPRO kindly requests that all providers include the fax request document with this bar code when submitting medical records to KEPRO. If there are multiple medical records or batches of records, please include the fax request document with the bar code as the first sheet of each batch. We anticipate that the use of these bar codes will provide a more efficient process when attaching medical records to the appeal review. It is anticipated that this modification could reduce the time needed for appeal reviews and allow KEPRO to provide a final determination sooner. If you have any questions, e-mail KEPRO.Communications@hcqis.org.
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Hospital Discharge Appeals
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When a beneficiary is in an acute setting receiving care that Medicare is paying for, they have a right to file an appeal when the physician writes an order to discharge. The hospital is responsible for sending medical records to KEPRO in a timely manner, and those records need to include the discharge plan for the beneficiary. Whether home with home health services or to a skilled nursing facility (SNF), clear documentation is required so that KEPRO knows that beneficiary has a safe discharge in place. It is vital to send current and updated case management or social services notes with the records; otherwise, if it is unknown if there is a safe discharge, the appeal may be closed out, and the beneficiary will remain in the facility until appropriate documentation is provided.
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Immediate Advocacy Success Story
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 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's wife contacted KEPRO with several concerns about her husband's care at the hospital. After visiting him, she was concerned that he had been overmedicated because he was in restraints. While he was in restraints, the staff put him in diapers and would not assist him to the bathroom. She stated that he was continent and could ambulate to the bathroom at admission. It took over nine hours for her husband's discharge to be completed, and then he was not provided with the correct prescription for his heart medicine.
The KEPRO Intake Specialist contacted the Quality Management Manager at the hospital. The manager explained that a sitter is always in the room when a patient is in restraints and assists with bathroom care and meals. She stated that she would refer the complaints to the Cardiac Unit Director and would overnight the prescriptions to the beneficiary. The Cardiac Unit Manager was aware of the complaints and stated she would follow up with her staff regarding the communication and discharge issues, treatment concerns, and the oversight of the correct prescription not being given to the beneficiary's wife. The hospital will be implementing a plan to make corrections.
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Higher Weighted Diagnosis-Related Group (HWDRG) Reviews
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When medical records are requested for a HWDRG claim, please be sure to submit the entire medical record related to the claim. This includes the physician's orders and medication administration records (MAR). Additionally, if the HWDRG claim was a result of a combined claim related to the Three-Day Payment Window, also known as the 72 Hour Rule, please submit the combined outpatient medical records with the inpatient records to enable an efficient review. Your cooperation with this is greatly appreciated.
If you have any questions relative to HWDRG record requests, submissions, or status, call 844-455-8708, extension 7475.
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With the onset of Round 3 Short Stay reviews, we would like to remind our providers to please submit your medical records using one of the following formats: CD with encryption, fax (844-242-2568), esMD (requires subscription), or paper (KEPRO Attn: Two Midnight Short-Stay Reviews, 5201 W. Kennedy Blvd., Suite 900, Tampa, FL 33609). Please be certain to submit all medical records at the same time, including the Medical Record Component Cover Sheet as the first page. Providers are reminded that our request is inclusive of orders and MARs, which are often missing in submissions. General information regarding eligible claims/medical records was included in the guidance contained in the CMS-1633 Final Rule publication, which remains valid (Reviewing Short Stay Hospital Claims for Patient Status: Admissions on or after January 1, 2016).
The BFCC-QIOs were notified on March 7, 2017, that the Short Stay review selection methodology has been refined. Beginning in April 2017, the Centers for Medicare & Medicaid Services (CMS) will sample the top 175 providers per service area with a high or increasing number of Short Stay claims with a request for 25 cases, and all other providers previously identified as having Major Concerns in the prior round of review will have a request for 10 cases. This targeted approach will allow CMS to improve oversight of hospital billing under the Two-Midnight policy.
The BFCC-QIOs were provided data files for the top 175 providers per service area with a high volume of Short Stay claims for the period from July 1, 2016, through December 21, 2016. The top 175 providers per service area will be refreshed prior to every new round of reviews. If you have specific
questions about the new sampling methodology and criteria, please send an e-mail to
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Q. With Short Stay reviews, what is the time frame for providers to receive a final determination after an educational session?
A. The provider has 10 days after an educational session to submit additional documentation; therefore, KEPRO waits more than 10 days prior to creating a final results letter.
Q. Once a facility has either Moderate or Major Concerns for Short Stay cases, what is the time frame that KEPRO schedules the one-on-one educational session? Is it still in the 45 days initial review window once they receive medical records?
A. KEPRO has 45 days to complete the initial review upon receipt of the provider's medical records.
If stratified as a Moderate Concern, the provider has 20 days to respond and choose to opt-in or out of a teleconference (optional for Moderate Concerns).
If stratified as a Major Concern, a teleconference is mandatory, and KEPRO will reach out to schedule the educational session within a couple of weeks, and/or the provider may reach out to KEPRO to schedule the session by calling 813-280-8256 ext. 7480.
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SAVE THE DATE!
Join us for a BFCC-QIO webinar! We offer three services to Medicare beneficiaries and their families: beneficiary complaints, discharge appeals, and Immediate Advocacy. This webinar will present a basic overview of these services as well as an introduction to some provider-based services.
What: The BFCC-QIO Program
Who: Healthcare providers and stakeholders
When: May 24, 2017, 2 p.m. - 3 p.m. ET
Speakers: Sylvia Gaddis, Outreach Specialist, KEPRO; Brittny Bratcher, Outreach Specialist, KEPRO
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