No. 10

Post-Acute Care Edition
Medical Director's Corner - Ferdinand Richards III, MD
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.
Person and Family Engagement
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.
New Process for Medical Records Submitted to KEPRO for Appeals
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 (MA) 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 .
Post-Acute Appeals
The NOMNC is issued to Medicare beneficiaries when they are receiving skilled care and the MA plan or provider feels that the services are no longer needed and Medicare will no longer pay for the services. The NOMNC must be issued at least two days prior to the skilled services ending in the skilled nursing facility setting. It is strongly suggested by the Centers for Medicare & Medicaid Services (CMS) that the notice be issued as close to the services ending as possible although the NOMNC can be given more than two days prior to the services ending. The notice must be signed and dated by the beneficiary or representative. If the beneficiary or representative is unable to sign, the NOMNC can be issued telephonically as long as all information is provided for a timely appeal and according to CMS guidelines and regulations found on the CMS website.
Immediate Advocacy Success Story
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 contacted KEPRO with concerns about his pain medications. He had shoulder replacement surgery and was sent to the rehabilitation facility. The physician at the rehabilitation facility did not want to write any more pain medication orders for him. The beneficiary was not scheduled for discharge for several more days and did not think he would be able to stay without the medication. The beneficiary visited his pain management physician and received a list of what he needed to take for his rehabilitation; however, his pain medications were still discontinued.
The KEPRO Intake Specialist contacted the rehabilitation facility's Administrator and found that the Administrator had met with the beneficiary, physician, social worker, and the nurse practitioner. All of the issues regarding the pain medications had been resolved. There were some items that the beneficiary used at home that were not protocol for the rehabilitation facility. However, the beneficiary had agreed to use what they were willing to provide. The KEPRO Intake Specialist received a call from the beneficiary expressing appreciation for her help in resolving the problem.
Post-Acute FAQs
Q. After an appeal has been started and the NOMNC has been rescinded, what is the best way to have the case closed by KEPRO?
A. The MA plan or the provider should notify KEPRO that the NOMNC has been rescinded.
Q. When a beneficiary makes someone his/her authorized representative, will the representative need to sign the form or can he/she give verbal permission? What's the process for authorizing someone?
A. CMS has a representative form that needs to be completed. The authorization to represent a beneficiary must be in writing.


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
Publication No. A234-478-5/2017. This material was prepared by KEPRO, a Medicare Quality Improvement Organization under contract 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.
Please do not copy/paste information from Case Review Connections. If you'd like to communicate BFCC-QIO information, please contact KEPRO at KEPRO.Communications@hcqis.org.