Discharge Appeals to be Rerouted by Kepro

Let’s start today with some Quality Improvement Organization (QIO) issues, specifically pertaining to Kepro.

First, I reported a few weeks ago that Kepro is changing its name to Acentra. For those who don’t know, Kepro was the peer review organization for Pennsylvania, also known as the Keystone State; hence, Kepro stands for Keystone Peer Review Organization. But now that Kepro is merging with CNSI, or Client Network Services, Inc., they will be rebranding to Acentra, a random assortment of letters that sounds appealing, but has no meaning whatsoever. But then again, have any of you seen the names of the newest cancer drugs, such as fam-trastuzumab deruxtecan-nxki?

But more importantly, Kepro/Acentra has made news with two things last week.

First, they announced that hospitals do not need to redo their Important Message from Medicare (IMM) forms to indicate their new name. So, until December 2025, when the current IMM approval expires, they will continue to accept the form with Kepro indicated as the QIO.

More significantly, Kepro is changing up its discharge appeal process. When a traditional Medicare patient calls to appeal their discharge, they are going to screen the call and somehow determine if the patient’s concern is with the discharge or the discharge planning. If it is the discharge planning, then instead of starting a formal appeal, they are going to initiate what they call an immediate advocacy process and get the patient and the hospital on the phone with them to try to resolve any misunderstanding. Now, of course, they do not say who will be moderating these calls, or what standards they will be using. They also do not address what happens if the patient calls in the evening or on the weekend. While this has the potential to avoid some appeals, it also may stretch out the actual appeal process even longer, meaning more patients in beds who do not require hospital care.

On the other hand, Kepro does provide in its explanation a nice list of questions that they will use to ask patients about their understanding of their discharge plan. The questions are:

• Has the hospital talked to you about your discharge plan?
• Where is your discharge destination, or have your location options been discussed?
• Has safe transportation been arranged?
• Do you understand the discharge plan?
• Do you have someone to assist you (if returning home)?
• Do you have the necessary durable medical equipment, or has delivery been arranged?
• Do you need home health services (if returning home), such as therapies or nursing care?
• Has the hospital provided information on community services?

I am also checking with the Centers for Medicare & Medicaid Services (CMS) to see if this process is even permitted. The discharge appeal process is highly regulated, and I am interested to know if CMS has authorized this since it places significant obligations on hospital personnel and theoretically may deprive a patient of a formal appeal.

Next, unrelated to the QIOs, and moving back to one of our recurring topics, the applicability of the Two-Midnight Rule to Medicare Advantage (MA) plans.

I’d like to issue a reminder that the Medicare Inpatient-Only List applies to every MA plan. A recent online discussion detailed a hospital that realized in April that for the last three months, one of their MA plans was not approving inpatient admission for such surgeries. Because they did not have inpatient approval, they performed them as outpatient and got paid outpatient rates. When they realized what was happening, they asked if they could go back and demand inpatient payments for the inpatient-only surgeries done in 2024. But sadly, the problem is that none of these surgeries had an inpatient admission order. The MA plan was wrong to approve them as outpatient, but the hospital did not know to push back and even submitted outpatient claims. To now go and try to correct the claims and insist the MA plan issue inpatient payment without an inpatient order just won’t work. The lesson here is to listen to Monitor Monday and read RACmonitor news to ensure you are up-to-date on the regulatory changes that matter.

Finally, I am delving into ICD10monitor territory here, but I want to pass on the contents of correspondence that Dr. Edward Hu had with CMS. The issue is the Medicare Advantage plans’ use of their own definitions for diseases for clinical validation audits.

Put simply, CMS said “Nope.” They stated that “coverage policies that dictate specific definitions of medical diagnoses to be additional coverage criteria that are only authorized in accordance with 42 § 422.101(b)(6).” And that section requires such policies to be developed in accordance with the medical literature and established treatment guidelines. So, no more random definitions of respiratory failure; feel free to report those violations to CMS just as you would if inpatient admission was denied for a case that met the Two-Midnight Rule.

Of course, the bad news for some is that the definition of sepsis requiring organ dysfunction is firmly established in the medical literature, so MA plans can continue to use that definition. But they cannot require the use of the Sequential Organ Failure Assessment (SOFA) score, since the definition of sepsis in that seminal article in JAMA does not require SOFA.

Now, what about the correct definition of acute respiratory failure? I will leave that to Dr. Erica Remer.