Expedited Determinations. Cheryl Cook, RN Program Director

Transcription

1 Expedited Determinations Cheryl Cook, RN Program Director 1

2 BFCC-QIO On August 1, 2014, KEPRO became the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for the Centers for Medicare & Medicaid Services (CMS) Areas 2, 3, and 4. The BFCC-QIO is responsible for beneficiary complaints and the discharge appeal process. 2

3 Objectives Explain the history of the expedited determination (ED) process Give an overview of the ED process Discuss the reconsideration process and how the process affects the provider and the patient Determine when it is appropriate to give the notice Discuss the barriers to effective delivery of the notice 3

4 History of the Process 1993: Grijalva v. Shalala lawsuit January 2004: Medicare Advantage (MA) appeals began July 2005: Fee-for-service (FFS) appeals began Part of the Balanced Budget Act 4

5 Impact on Beneficiaries Gives notice of impending termination of skilled services Protects the rights of Medicare beneficiaries Establishes financial liability 5

6 Impact on Providers CMS audits the process. Invalid notices cost money, waste time, and can confuse patients. 6

7 Responsibilities of the Provider The notice is issued when ALL skilled services are no longer required. Even if the beneficiary agrees with the discharge, ISSUE the notice! 7

8 Expedited Determination Process Overview The provider issues the notice. The beneficiary or representative calls for an appeal. KEPRO requests the record. The record is reviewed by the KEPRO physician. The beneficiary and facility (and plan if necessary) are notified of the decision. 8

9 Validating the Notice KEPRO will validate the notice when the appeal is requested. The following will invalidate the notice: Wrong form Missing documentation Wrong time frames Wrong dates Wrong QIO phone number Missing MA organization s name on notice 9

10 Medical Record Review KEPRO s physician reviews the record and determines if the beneficiary is ready to be discharged from skilled services. If there is incomplete or inconsistent documentation, the physician will generally find in favor of the beneficiary. 10

11 Review Determination Once the KEPRO physician has made a determination, KEPRO will notify the beneficiary, provider, and plan, if applicable. The notification will be made by close of business the day after the necessary information is received. 11

12 Time Frames The review will be completed within one day of receipt of all of the necessary medical record components. 12

13 Reconsiderations FFS beneficiaries: Maximus completes the second review. MA beneficiaries: KEPRO completes the second review. A second physician not involved with the original decision reviews the chart. 13

14 Administrative Law Judge If the reconsideration does not go in the beneficiary s favor, they can appeal to the Administrative Law Judge (ALJ). This appeal is only for financial liability in excess of $

15 When the Notice is Not Required Therapy caps (Part B) Admission to higher level of care Unsafe environment e.g., Home Health unsafe neighborhood Patient moves out of the area Patient signs up for Hospice Patient exhausts their benefits 15

16 KEPRO Availability KEPRO appeals staff work (local time): Weekdays: 9 am - 5 pm Weekends: 11 am - 3 pm Holidays: 11 am - 3 pm Voic s may be left during all other hours. Review time frames still apply on weekends and holidays. 16

17 Obtaining the Notice Beneficiary Notices Initiative (BNI) 17

18 Request for Documents Upon request, the provider or MA plan must provide the beneficiary the documentation sent to KEPRO. 18

19 Issues Related to Delivery Patient won t sign Patient is unable to speak for themselves Representative won t acknowledge Representative gives excuses 19

20 Representatives Legal types E.g., power of attorney, health care surrogate Deferring to state law E.g., next of kin, anyone acting in the best interest of the beneficiary 20

21 Issues Related to Weekend Staff Weekend staff should: Know who KEPRO is and its role in processing appeals Be familiar with the notices and able to locate them Know how to reissue the notice Know they can give protected health information (PHI) to KEPRO 21

22 Tips for Success Staff education Short, concise delivery Standard notice for all situations Develop a process and stick to it Copy for the patient, copy for the chart 22

23 Additional Information For additional information, visit our website, 23

24 Questions 24

25 All material presented or referenced herein is intended for general informational purposes and is not intended to provide or replace the independent judgment of a qualified healthcare provider treating a particular patient. KEPRO disclaims any representation or warranty with respect to any treatments or course of treatment based upon information provided. Publication No. A /2014. 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. 25