The newsletter reveals a startling revelation.
Last week Kepro, the BFCC-QIO (Beneficiary and Family Centered Care Quality Improvement Organization), hereafter referred to as “QIO”) for part of the country, released their monthly newsletter called Case Connections. In each issue, there is a little blurb from the medical director describing a recent initiative by the Centers for Medicare & Medicaid Services (CMS) or Kepro. To steal terminology from Reddit, this is usually “mildly interesting” at best. But if you stop reading there, you miss the good stuff.
This month they described Kepro’s online appeal tracking tool, even including a link to a YouTube video tutorial. I am a vendor and not in the hospital directly handling patient appeals so this might be old news but I did not know you could go online and see exactly where the patient’s appeal was in the process. I have heard of instances when the QIO is not so timely with their decision so this is a great way to track that and get written proof if you choose to escalate their poor performance to CMS.
What is a timely decision from the QIO on a patient appeal? Well, it is complicated. The Medicare Claims Processing Manual, chapter 30, section 200.5.6 states, “No later than one calendar day after it receives all requested information, the BFCC-QIO must make its determination on whether the discharge is appropriate based on medical necessity or other Medicare coverage policies.” So it is not a 24-hour period but the decision must be available by the end of the day on the day after they receive the information. How does CMS define the end of the day? Who knows…
Now what should you do if your QIO is not meeting the timeliness requirement? While patients can call 1-800-MEDICARE or the QIO if they have a complaint about hospitals, and Livanta even has a smartphone app so there is no “dialing” involved, there is no simple way to complain to CMS about the QIO. I would advise contacting your CMS Regional Office and asking them for help. It is important for CMS to understand that when patients are hospitalized and staying to await their appeal decision, the hospital incurs real costs to provide that care and any delays in receiving the QIO decisions costs money.
And as important as it is to report poor performance, do not forget to take the time to acknowledge excellent performance. If the QIO helps you out of a bind with a patient situation, thank them. If a specific employee goes out of their way to help you, contact their boss to ensure their work is recognized.
The other part of the newsletter that is always interesting to read is their “immediate advocacy success story.” This is where they get to brag about their good work.
This month they described the patient who was discharged from the hospital and the prescriptions were not available at the pharmacy as requested so the husband called Kepro for help. Kepro called the hospital and found out that the prescriptions were called to a different pharmacy because the requested pharmacy was closed for the weekend.
They called the patient’s husband with this information. As Kepro describes it, the husband expressed appreciation. But what struck me was the statement that “the pharmacy staff was called and stated they were working on filling the 18 prescriptions.”
Eighteen prescriptions? Seriously? Can you imagine the drug interactions that happen inside that patient’s body? What is wrong with us that someone would think it appropriate to prescribe that many medications to one person? I would hope that if any of you encounter a patient on 18 medications you would talk to the doctor about a careful medication review and start deprescribing some medications.
This is also a good time to remind you that while we think about the QIO for patient discharge appeals, they are also available for patients to call with almost any issue as we saw in this case. If the patient does not like the food or their roommate, they can call the QIO. So if the QIO calls you, it may simply be a fact-finding call and not an official action. You may want to talk to your staff about how to handle such a call. How do you verify that they really are who they say they are? How much information can you release to them? At what point do you need to involve compliance or risk?
The Centers for Medicare & Medicaid Services (CMS) released in its 2025 Outpatient Prospective Payment System (OPPS) Final Rule a new Conditions of Participation (CoPs)
External audit volume more than doubled in 2024 over 2023 while total at-risk dollars increased fivefold to $11.2 million, impacting healthcare provider organizations’ cash flow
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 ICD10monitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
