AREA #5 BFCC-QIO 11TH SOW ANNUAL MEDICAL SERVICES REPORT 08/01/ /31/2016

Transcription

1 AREA #5 BFCC-QIO 11TH SOW ANNUAL MEDICAL SERVICES REPORT 08/01/ /31/2016

2 TABLE OF CONTENTS TABLE OF CONTENTS... 2 INTRODUCTION:... 1 Livanta QIO Area #5 Summary ) Total # of Reviews ) Top 10 Principal Medical Diagnoses: ) Provider Reviews Settings: ) Quality of Care Concerns Confirmed ) Discharge/Service Termination ) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by Notification Type ) Evidence Used in Decision-Making ) Reviews by Geographic Area ) Outreach and Collaboration with Beneficiaries ) Immediate Advocacy Reviews ) Example/Success Story ) Beneficiary Helpline Statistics CONCLUSION: APPENDIX Livanta QIO AREA #5 State of Alaska ) Total # of Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care Concerns Confirmed ) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by Notification Type ) Reviews by Geographic Area Urban and Rural ) Immediate Advocacy Reviews Livanta QIO AREA #5 State of Arizona ) Total # of Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care Concerns Confirmed ) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by Notification Type... 33

3 7) Reviews by Geographic Area Urban and Rural ) Immediate Advocacy Reviews Livanta QIO AREA #5 State of California ) Total # of Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care Concerns Confirmed ) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by Notification Type ) Reviews by Geographic Area Urban and Rural ) Immediate Advocacy Reviews Livanta QIO AREA #5 State of Hawaii ) Total # of Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care Concerns Confirmed ) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by Notification Type ) Reviews by Geographic Area Urban and Rural ) Immediate Advocacy Reviews Livanta QIO AREA #5 State of Idaho ) Total # of Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care Concerns Confirmed ) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by Notification Type ) Reviews by Geographic Area Urban and Rural ) Immediate Advocacy Reviews Livanta QIO AREA #5 State of Nevada ) Total # of Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care Concerns Confirmed... 63

4 6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by Notification Type ) Reviews by Geographic Area Urban and Rural ) Immediate Advocacy Reviews Livanta QIO AREA #5 State of Oregon ) Total # of Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care Concerns Confirmed ) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by Notification Type ) Reviews by Geographic Area Urban and Rural ) Immediate Advocacy Reviews Livanta QIO AREA #5 State of Washington ) Total # of Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care Concerns Confirmed ) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by Notification Type ) Reviews by Geographic Area Urban and Rural ) Immediate Advocacy Reviews... 82

5 INTRODUCTION: Livanta LLC is the Centers for Medicare & Medicaid Services (CMS) designated Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for Area 5, which includes the states of Alaska, Arizona, California, Hawaii, Idaho, Nevada, Oregon, and Washington, as well as the territories of Guam, American Samoa, and the Northern Mariana Islands. The QIO Program, one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries, is an integral part of the U.S. Department of Health and Human (HHS) Services' National Quality Strategy for providing better care and better health at lower cost. By law, the mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. CMS identifies the core functions of the QIO Program as: Improving quality of care for beneficiaries; Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting; and Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law. BFCC-QIOs improve healthcare services and protect beneficiaries through expeditious statutory review functions, including complaints and quality of care reviews for people with Medicare. The BFCC-QIO ensures consistency in the case review process while taking into consideration local factors and local needs for general quality of care, medical necessity, and readmissions. 1 This annual report provides data regarding case reviews that were completed on behalf of Medicare beneficiaries and their representatives, health care providers, and CMS for the date range of August 1, 2015 through July 31, Readers will find the overall Area 5 data in the first 12 sections of this report, and state specific data in the Appendix section of the report. This report underscores our commitment to transparency by providing key performance metrics from the second year of Livanta s work with Medicare beneficiaries. Livanta understands and respects beneficiaries rights and concerns, and we are dedicated to protecting patients by reviewing appeals and quality complaints in an effective and efficient patient-centered manner. For more information on Livanta s performance metrics, please visit our online dashboard. 1 Quality Improvement Organizations. CMS.gov. Centers for Medicare & Medicaid Services. September 12, Web. September 29, P a g e

6 LIVANTA QIO AREA #5 SUMMARY 1) TOTAL # OF REVIEWS Livanta completed reviews on behalf of Medicare beneficiaries receiving care in Area 5. This table breaks out the number of reviews by the different types of reviews we conducted. Review Type # of Reviews Percent of TOTAL Reviews Coding Validation (120 - HWDRG) 2 6, % Coding Validation (All Other Selection Reasons) % Quality of Care Review (101 through Beneficiary Complaint) 1, % Quality of Care Review (All Other Selection Reasons) % Utilization (158 - FI/MAC Referral for Readmission Review) % Utilization (All Other Selection Reasons) 17, % Notice of Non-coverage (105 through Admission and Preadmission) % Notice of Non-coverage (118 - BIPA) 6, % Notice of Non-coverage (117 - Grijalva) 12, % Notice of Non-coverage (121 through Weichardt) 9, % Notice of Non-coverage (111 - Request for QIO Concurrence) % Emergency Medical Treatment & Labor Act (EMTALA) 5 Day % EMTALA 60 Day % Total 54, % 2 Coding Validations and Utilization Reviews: Livanta reviews medical records to verify that the coding is accurate, that the care provided was medically necessary, and that the care provided was delivered in the most appropriate setting. Certain hospital claims submitted as part of hospital billing trigger reviews by Livanta, as the proposed changes to billing codes would allow the hospital to receive more money for the care delivered. Currently, CMS refers all claims of this type in Area 5 to Livanta for review. We ensure that the care provided accurately matches the provider s claim for payment, and that the claim was coded correctly for billing purposes. 3 EMTALA Reviews: Livanta reviews cases that may be in violation of the Emergency Medical Treatment and Labor Act (EMTALA). EMTALA is a federal law requiring that patients who need stabilization for an emergency medical condition receive that care, regardless of their ability to pay. CMS refers cases of this kind to Livanta in Area 5 on an as-needed basis. We determine whether the medical screening was adequate, whether an emergency medical condition existed, and if so, whether the patient was stabilized before a transfer. We also review the quality of care provided. 2 P a g e

7 2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES: BFCC-QIO 11 th SOW Annual Medical Services Report This table provides information regarding the top 10 medical diagnoses for inpatient claims billed during the annual reporting period for Medicare patients in Area 5. Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries 1. A419 - SEPSIS, UNSPECIFIED ORGANISM 74, % SEPTICEMIA NOS 30, % 3. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 28, % 4. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 19, % 5. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL 19, % INFARCTION 6. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W (ACUTE) 17, % EXACERBATION 7. N390 - URINARY TRACT INFECTION, SITE NOT 16, % SPECIFIED 8. I639 - CEREBRAL INFARCTION, UNSPECIFIED 12, % 9. M UNILATERAL PRIMARY OSTEOARTHRITIS, 12, % RIGHT KNEE 10. I ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) 11, % HEART FAILURE Total 241, % 3 P a g e

8 3) PROVIDER REVIEWS SETTINGS: BFCC-QIO 11 th SOW Annual Medical Services Report This table provides information on the count and percent by setting for Health Service Providers (HSPs) associated with a completed BFCC-QIO review in Area 5. Setting # of Providers Percent of Providers 0: Acute Care Unit of an Inpatient Facility % 1: Distinct Psychiatric Facility % 2: Distinct Rehabilitation Facility % 3: Distinct Skilled Nursing Facility 1, % 5: Clinic % 6: Distinct Dialysis Center Facility % 7: Dialysis Center Unit of Inpatient Facility % 8: Independent Based RHC % 9: Provider Based RHC % C: Free Standing Ambulatory Surgery Center % G: End Stage Renal Disease Unit % H: Home Health Agency % N: Critical Access Hospital % O: Setting Does Not Fit Into Any Other Existing Setting Code % Q: Long-Term Care Facility % R: Hospice % S: Psychiatric Unit of an Inpatient Facility % T: Rehabilitation Unit of an Inpatient Facility % U: Swing Bed Hospital Designation for Short-Term, Long- Term Care, and Rehabilitation Hospitals % Y: Federally Qualified Health Centers % Z: Swing Bed Designation for Critical Access Hospitals % Other % Total 2, % 4 P a g e

9 4) QUALITY OF CARE CONCERNS CONFIRMED This table provides the number of confirmed quality of care concerns as identified by Physician Reviewer Assessment Form (PRAF) category codes within the CMS Case Review Information System (CRIS). These quality of care concerns are confirmed by Livanta s independent physician reviewers as care that did not meet the professionally recognized standards of medical care. Confirmed quality of care concerns are provided education and referred as appropriate to the CMS designated Quality Innovation Network Quality Improvement Organization (QIN-QIO) contractors who work with providers to make improvements in patient care. Quality of Care ( C Category) PRAF Category Codes # of Concerns # of Concerns Confirmed Percent Confirmed Concerns # of Concerns Referred as Quality Improvement Initiatives (QII) C01: Apparently did not obtain pertinent history and/or findings from examination % 0 C02: Apparently did not make appropriate diagnoses and/or assessments % 23 C03: Apparently did not establish and/or develop an appropriate treatment plan for a defined problem or diagnosis which prompted this episode of care [excludes laboratory and/or imaging (see C06 or C09) and procedures (see C07 or C08) and consultations (see C13 and C14)] C04: Apparently did not carry out an established plan in a competent and/or timely fashion C05: Apparently did not appropriately assess and/or act on changes in clinical/other status results C06: Apparently did not appropriately assess and/or act on laboratory tests or imaging study results C07: Apparently did not establish adequate clinical justification for a procedure which carries patient risk and was performed C08: Apparently did not perform a procedure that was indicated (other than lab and imaging, see C09) C09: Apparently did not obtain appropriate laboratory tests and/or imaging studies C10: Apparently did not develop and initiate appropriate discharge, follow-up, and/or rehabilitation plans 1, % % % % % % % % 18 5 P a g e

10 Quality of Care ( C Category) PRAF Category Codes BFCC-QIO 11 th SOW Annual Medical Services Report # of Concerns # of Concerns Confirmed Percent Confirmed Concerns # of Concerns Referred as Quality Improvement Initiatives (QII) C11: Apparently did not demonstrate that the patient was ready for discharge % 0 C12: Apparently did not provide appropriate personnel and/or resources % 1 C13: Apparently did not order appropriate specialty consultation % 2 C14: Apparently specialty consultation process was not completed in a timely manner % 2 C15: Apparently did not effectively coordinate across disciplines % 5 C16: Apparently did not ensure a safe environment (medication errors, falls, pressure ulcers, transfusion reactions, nosocomial % 15 infection) C17: Apparently did not order/follow evidencebased practices % 4 C18: Apparently did not provide medical record documentation that impacts patient care % 4 C40: Apparently did not follow up on patient s non-compliance % 0 C99: Other quality concern not elsewhere classified % 10 Total 4, % 176 5) DISCHARGE/SERVICE TERMINATION This table provides information regarding the discharge location of beneficiaries linked to appeals conducted by Livanta of provider-issued notices of Medicare non-coverage. Data contained in this table represents discharge/termination of service reviews from August 1, 2015 through April 30, A shortened timeframe is necessary to allow for maturity of claims data, which are the source of Discharge Status for these cases. Discharge Status 01: Discharged to home or self care (routine discharge) 02: Discharged/transferred to another short-term general hospital for inpatient care 03: Discharged/transferred to skilled nursing facility (SNF) # of Beneficiaries Percent of Beneficiaries % % 1, % 6 P a g e

11 Discharge Status # of Beneficiaries Percent of Beneficiaries 04: Discharged/transferred to intermediate care facility (ICF) % 05: Discharged/transferred to another type of institution (including distinct parts) % 06: Discharged/transferred to home under care of organized home health service organization % 07: Left against medical advice or discontinued care % 09: Admitted as an inpatient to this hospital % 20: Expired (or did not recover Christian Science patient) % 21: Discharged/transferred to court/law enforcement % 30: Still a patient % 40: Expired at home (Hospice claims only) % 41: Expired in a medical facility (e.g. hospital, SNF, ICF or free standing Hospice) % 42: Expired place unknown (Hospice claims only) % 43: Discharged/transferred to a Federal hospital 1 003% 50: Hospice - home % 51: Hospice - medical facility % 61: Discharged/transferred within this institution to a hospital-based Medicare approved swing bed % 62: Discharged/transferred to an inpatient rehabilitation facility including distinct part units % of a hospital 63: Discharged/transferred to a long term care hospital % 64: Discharged/transferred to a nursing facility certified under Medicaid but not under Medicare % 65: Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital % 66: Discharged/transferred to a Critical Access Hospital % 70: Discharged/transferred to another type of health care institution not % defined elsewhere in code list Other % Total 3, % 7 P a g e

12 6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE This table provides the number of appeal reviews and the percentage of reviews, specifically for each outcome, in which Livanta s independent physician reviewer agreed or disagreed with the discharge. Appeal Review by Notification Type 105: Notice of Non-coverage FFS Preadmission Notice Concurrent Immediate Review 106: Notice of Non-coverage FFS Preadmission Notice Non-immediate Review 107: Notice of Non-coverage FFS Admission Notice Concurrent Immediate Review 108: Notice of Non-coverage FFS Admission Notice Non-immediate Review 111: Notice of Non-coverage Request for QIO Concurrence 117: MA Appeal Review (CORF, HHA, SNF) 118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 121: Notice of Non-coverage Continued Stay Notice Immediate Review - Attending Physician Concurs 122: Notice of Non-coverage Continued Stay Notice Concurrent Non-immediate Review 123: Notice of Non-coverage Continued Stay Retrospective 124: MA Notice of Non-coverage Continued Stay Notice Immediate Review - Attending Physician Concurs # of Reviews Physician Reviewer Disagreed with Discharge Physician Reviewer Agreed with Discharge % 78.57% % % % 80.00% % 0.00% % % 10, % 81.92% 5, % 82.87% 3, % 93.86% % 82.72% % 84.74% 3, % 93.34% Total 24, % 85.90% 8 P a g e

13 7) EVIDENCE USED IN DECISION-MAKING The following table describes one or more of the most common types of evidence or standards of care used to support Livanta s review coordinators and independent physician reviewer decisions for medical necessity/utilization review and appeals. Livanta uses evidence-based guidelines and medical literature to identify standards of care, where such standards exist. For quality of care reviews, we have provided one to three of the most highly utilized types of evidence/standards of care to support Livanta s review coordinator and independent physician reviewer decisions for the specific list of diagnostic categories provided in this table. A brief statement of the rationale for selecting the specific evidence or standards of care is also included. Review Type Diagnostic Categories Evidence/ Standards of Care Used Quality of Care Pneumonia UpToDate: Treatment of Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia in adults Rationale for Evidence/Standard of Care Selected UpToDate is a web-based resource that provides multiple evidence based standards of care and clinical decision support. Heart Failure Pressure Ulcers Acute Myocardial Infarction Urinary Tract Infection Sepsis UpToDate: Evaluation of the Patient with Suspected Heart Failure UpToDate: Clinical Staging and Management of Pressure Ulcers UpToDate: Overview of the Acute Management of ST Elevation Myocardial Infarction UpToDate: Acute Complicated Cystitis and Pyelonephritis UpToDate: Sepsis and the Systemic Inflammatory Response Syndrome: Definitions, Epidemiology, and Prognosis UpToDate is a web-based resource that provides multiple evidence based standards of care and clinical decision support. UpToDate is a web-based resource that provides multiple evidence based standards of care and clinical decision support. UpToDate is a web-based resource that provides multiple evidence based standards of care and clinical decision support. UpToDate is a web-based resource that provides multiple evidence based standards of care and clinical decision support. UpToDate is a web-based resource that provides multiple evidence based standards of care and clinical decision support. 9 P a g e

14 Review Type Diagnostic Categories Evidence/ Standards of Care Used Quality of Care Adverse Drug Events UpToDate: Drug Prescribing for Older Adults Falls Patient Trauma Surgical Complications UpToDate: Falls: Prevention in Nursing Care Facilities and the Hospital Setting UpToDate: Initial Management of Trauma in Adults UpToDate: Surgical Complications/Procedure Specific Rationale for Evidence/Standard of Care Selected UpToDate is a web-based resource that provides multiple evidence based standards of care and clinical decision support. UpToDate is a web-based resource that provides multiple evidence based standards of care and clinical decision support. UpToDate is a web-based resource that provides multiple evidence based standards of care and clinical decision. UpToDate is a web-based resource that provides multiple evidence based standards of care and clinical decision support. Review Type Medical Necessity/Utilization Review Evidence/ Standards of Care Used MCG and InterQual Rationale for Evidence/Standard of Care Selected MCG and InterQual are standard, evidence-based criteria used to assess when and how individual patients progress through the continuum of care. Livanta also applies CMS's Two Midnight Rule, which states that inpatient admissions are generally appropriate if the admitting practitioner expected the patient to require a hospital stay that crossed two midnights and the medical record supports that reasonable expectation. 10 P a g e

15 Review Type Appeals Evidence/ Standards of Care Used Medicare Benefit Policy Manual Medicare Managed Care Guidelines, Chapter 13 CMS Beneficiary Notices Initiative (BNI) website CMS Publication , Medicare Claims Processing Manual, Chapter 30: Financial Liability Protections The Medicare Quality Improvement Organization Manual, Publication , Chapter 7- Denials, Reconsiderations, & Appeals Local Coverage Determinations (LCDs) BFCC-QIO 11 th SOW Annual Medical Services Report Rationale for Evidence/Standard of Care Selected According to the Medicare Benefit Policy Manual, Chapter 8, care in a skilled nursing facility (SNF) is covered if four factors are met. Physician reviewers apply those four requirements to each case reviewed. If ANY ONE of those four factors is not met, a stay in a SNF, even though it might include delivery of some skilled services, is not covered. Reconsideration timing: If the QIO upholds a Medicare health plan s decision to terminate services in whole or in part, the enrollee may request, no later than 60 days after notification that the QIO has upheld the decision, that the QIO reconsider its original decision. Forms, model letter template language, and instructions for providers: The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. Instructions regarding hospital interactions with QIOs: Before Medicare can pay for post-hospital extended care services, it must determine whether the beneficiary had a prior qualifying hospital stay of at least three consecutive calendar days. This includes related instructions for the Quality Improvement Organization (QIO) processing of Appeals These are coverage determinations for specific situations and they are published by Medicare Administrative Contractors for cases within their own jurisdiction. 11 P a g e

16 Review Type Appeals Evidence/ Standards of Care Used Code of Federal Regulations Rationale for Evidence/Standard of Care Selected Requesting immediate QIO review of the decision to discharge from the inpatient hospital: Procedures the QIO must follow: (1) When the QIO receives the request for an expedited determination under paragraph (b)(1) of this section, it must immediately notify the hospital that a request for an expedited determination has been made. (2) The QIO determines whether the hospital delivered valid notice consistent with (b)(3). (3) The QIO examines the medical and other records that pertain to the services in dispute. (4) The QIO must solicit the views of the beneficiary (or the beneficiary's representative) who requested the expedited determination. (5) The QIO must provide an opportunity for the hospital to explain why the discharge is appropriate. 12 P a g e

17 8) REVIEWS BY GEOGRAPHIC AREA These tables provide information for Area 5 about the count and percentage by rural vs. urban geographical locations for Health Service Providers (HSPs) associated with a completed BFCC-QIO review. Table 8A provides data for Appeals, and Table 8B provides data for Quality of Care reviews. Table 8A: Appeals Reviews by Geographic Area Urban and Rural: Geographic Area # of Providers Percent of Providers in Service Area Appeal Reviews Urban 2, % Rural % Unknown % Total 2, Table 8B: Quality of Care Reviews by Geographic Area Urban and Rural: Geographic Area # of Providers Percent of Providers in Service Area Quality of Care Reviews Urban % Rural % Unknown % Total % 13 P a g e

18 9) OUTREACH AND COLLABORATION WITH BENEFICIARIES Overview The outreach and communication efforts of Livanta are designed to generate and maintain a regular flow of information to major stakeholders and to educate customers on the role and purpose of the BFCC-QIO. Ensuring relevant parties have access and exposure to this information is vital to quality control, efficient use of resources, and a positive customer experience as it increases situational understanding to all parties involved. The availability of information and education initiatives allows Livanta to clearly establish expectations with customers and providers and to educate stakeholders on the role and purpose of each player. Employing regularly used platforms of communication, Livanta provides pertinent information to stakeholders in an efficient and effective manner. This document outlines Livanta s efforts to provide user-friendly access of information and educational efforts to all major stakeholders in the BFCC-QIO process. Beneficiaries and Families To ensure that beneficiaries and their family members have access to the services of the BFCC-QIO, Livanta provides a toll-free HelpLine at The HelpLine also maintains a TTY line at for use by the hearing impaired. In order to remove any potential language or cultural barriers to using the services of the BFCC-QIO, Livanta retains a translation firm to translate voice conversations in real-time as well as to translate any written correspondence into the language of choice for the beneficiary. Additionally, Livanta s Intake Center is fully bilingual, offering immediate Spanish language support for callers. In order to better engage the more technology oriented beneficiary, and their family members and advocates, Livanta continues to develop and promote the use of the Medicare Quality HelpLine smartphone app. Users may download the app and automatically connect with a nurse who can help begin the process of filing a quality of care complaint or an appeal. In addition, Livanta continues to develop and promote the Arrow program on the Livanta BFCC-QIO website. Arrow allows a user to access up-to-the-minute status information on individual cases while protecting sensitive information. Successful Engagement One of the most critical roles that Livanta has in the BFCC-QIO Program is the mission to extend outreach to vulnerable and isolated populations. Through the course of the year, Livanta has targeted many stakeholder advocate groups who represent such demographics. During an outreach trip to Area 5, the Communications Team met with the Area Agency on Aging for Northern Idaho (AAANI). This umbrella office represents the interests of Medicare beneficiaries in the 5 most extreme northern counties of Idaho. This geographic locality is extremely isolated from Idaho s largest city. After the outreach visit, representatives from AAANI requested a follow-up webinar to train members of their staff on the role and services of Livanta as BFCC-QIO. After visiting and conducting this training, Livanta s Intake Center noted a 20% increase in case volume for the northern counties of Idaho. This successful engagement of a rural and isolated population is but one example of Livanta s commitment to directly reaching out to all populations and removing any potential barriers to the BFCC-QIO Program. 14 P a g e

19 Providers BFCC-QIO 11 th SOW Annual Medical Services Report Livanta continues to regularly and consistently engage the provider community through webinars, presentations, and publications to support ongoing provider education. The information presented can be used by all of Livanta s provider community to better understand the role of the BFCC-QIO program in the delivery of quality healthcare. Livanta s BFCC-QIO content is routinely updated to keep providers informed about program requirements, CMS updates, news of interest, and frequently asked questions. Allowing both provider and beneficiary access to the Arrow program helps facilitate synchronicity of information amongst stakeholders. In addition to the regular provider communications and web-based electronic platforms, Livanta continues to engage provider associations to more efficiently disseminate information in a timely and targeted fashion. This proactive engagement of the provider community promotes a better understanding of the BFCC-QIO program as well as the rapid dissemination of critical programmatic information. Advocates Through consistent and targeted outreach, Livanta has engaged directly with advocate groups in every state and territory in Area 5. Livanta maintains regular contact with area agencies on aging, SHIP (State Health Insurance Assistance Program) and SHIBA (Senior Health Insurance Benefits Assistance Program) offices at the state and regional level as well as state ombudsman programs, Congressional constituent services offices, and ethnic and cultural advocacy groups. In the past year, Livanta has had on-site collaboration meetings with 50 critical advocate stakeholders. In order to conduct these meetings, Livanta has invested considerable research time to identify the most effective partner-advocates. Meetings were held on-site in various states, including Arizona, California, Idaho, Nevada, Oregon, and Washington. Livanta also proactively engages the health staff of members of the House of Representatives and the United States Senate. These meetings provide valuable insight into regionally-specific issues facing beneficiary populations in the home districts. In the past year, Livanta has conducted one-on-one briefings with 91 Congressional offices in Area 5. With the successful completion of those visits, Livanta has now met with staff from all of the Area 5 Members of Congress. Additionally, efforts are ongoing to stay in close communication with advocates of religious, cultural, ethnic, and senior groups in order to facilitate engagement and education as Livanta innovates to meet the changing needs of Medicare beneficiaries. Education through Communication Because of the rapidly changing nature of healthcare, Livanta is committed to providing up-to-date BFCC-QIO information to the general public, stakeholders, providers, and advocates. To educate customers on these updates, the CMS Twitter is featured live on Livanta s website. The Livanta BFCC-QIO website is available for beneficiaries to access in 10 different languages, and each of the languages represented on the website reflect either a high volume of speakers in Area 5 or a vulnerable population in Area 5. Thanks to direct feedback obtained during an outreach trip to meet Congressional staff from Hawaii, it was determined that Japanese language support was needed, and it was subsequently added to Livanta s BFCC-QIO webpage. Thanks to consistent education and outreach, utilization of Livanta s BFCC-QIO webpage has resulted in 129,008 unique users. Each user represents an individual beneficiary, family member or advocate accessing the resources and information on the website. 15 P a g e

20 Other Partners BFCC-QIO 11 th SOW Annual Medical Services Report Livanta maintains a close working relationship with CMS and regularly collaborates with the Contracting Officer Representatives (CORS) assigned to the Livanta contract. Livanta also works in conjunction with other Medicare contractors who support the BFCC-QIO, and will often combine resources to sponsor outreach initiatives for increased efficiency and effectiveness. 10) IMMEDIATE ADVOCACY REVIEWS Immediate Advocacy is an informal, voluntary process used by Livanta to resolve complaints quickly. This process begins when the beneficiary or his or her representative contacts Livanta and gives verbal consent to proceed with the complaint. Once consent is given, Livanta contacts the provider and/or practitioner on behalf of the Medicare patient. Immediate Advocacy is not appropriate when a patient wants to remain anonymous. Immediate Advocacy does not take the place of a clinical quality of care review, which includes an assessment of the patient s medical records. # of Beneficiary Complaints # of Immediate Advocacy Reviews Immediate Advocacy Reviews of Total Beneficiary Complaints Resolved by Immediate Advocacy 1, % 11) EXAMPLE/SUCCESS STORY Quality Success Stories Example 1: A representative for a Medicare beneficiary reported that there was a communication breakdown between the beneficiary s infectious disease (ID) physician, the primary care physician (PCP), and the laboratory. The representative complained that the PCP informed her that the order, labs, and medical records were faxed and mailed to the ID physician's office in order to schedule the appointment, but the ID office neither scheduled the appointment nor turned away the referral. The representative felt that the beneficiary s infections were getting worse and that he needed care. Livanta s Review Coordinator contacted the ID physician s office. The Review Coordinator was told by the office staff that they did not have the correct contact information for the beneficiary, and they were waiting for a call to schedule an appointment. The office was given the beneficiary's contact information and was informed that a call would be placed to the beneficiary immediately to schedule the appointment. The Review Coordinator then followed up with the beneficiary s representative to confirm that the appointment was successfully completed. 16 P a g e

21 Example 2: BFCC-QIO 11 th SOW Annual Medical Services Report A Medicare beneficiary s daughter called Livanta to request assistance for complaints against a facility. The daughter reported the following concerns: 1) The medication that her mother was receiving was causing her to have psychotic episodes and leading her to attempt to pull her tracheostomy out. The daughter felt that the medication should not be administered because her mother was neither agitated nor disruptive. 2) The beneficiary was having gastric tube (GT) feeding problems (heartburn and vomiting) and felt the problem was not being adequately addressed. Livanta s Review Coordinator (RC) contacted the provider s Director of Nursing to discuss the reported quality of care concerns. As a result of the Immediate Advocacy discussions, additional assessments of the beneficiary s condition were made and the following changes were implemented: Physician orders were obtained to discontinue Haldol and Morphine, and to change the beneficiary s medication to Ativan. The medication change provided a better affect for the beneficiary and stopped the psychotic episodes. A dietician consultation was ordered to address the GT feedings. The dietician assisted with regulating the beneficiary s GT formula and medication was ordered to assist with the secretions and vomiting problems. Speech therapy was ordered for the beneficiary with the goal of terminating the need for a GT. Staff education was conducted on beneficiary rights and the need for better communication between the patient, family representative, and rehabilitation staff. 12) BENEFICIARY HELPLINE STATISTICS This table provides Livanta s Area 5 beneficiary HelpLine statistics for the period from August 1, 2015 through July 31, Beneficiary Helpline Report Total Per Category Total Number of Calls Received 98,391 Total Number of Calls Answered 83,395 Total Number of Abandoned Calls 2,083 Average Length of Call Wait Times 0:13 seconds Number of Calls Transferred by Medicare 2, P a g e

22 CONCLUSION: Livanta s quality improvement efforts result in the protection of beneficiaries by ensuring that the quality of health care they receive meets professionally recognized standards of care. During the course of the second year of their contract, Livanta received 98,391 calls from beneficiaries, collaborated with 2,378 providers, and met personally with 141 critical stakeholders. All of these interactions are important to the Medicare program. The QIOs support CMS s initiative of ensuring that all Medicare beneficiaries receive good quality care every time care is needed. That goal entails ensuring that medical care is paid for by Medicare when it is medically necessary, and that the care provided meets the standards of care set by the medical community. The QIOs support Medicare beneficiaries and providers through the care continuum. During these interactions, Livanta is able to provide information, education, and determinations that support the Medicare program. The significance of these interactions cannot be understated. Through review of beneficiary complaints and appeals, Livanta ensures that the perspective and unique needs of beneficiaries and their representatives are heard, understood, and considered - both in making decisions about current care and in helping health care facilities provide better care for all beneficiaries in the future. Through the Immediate Advocacy segment of Livanta s role as BFCC-QIO, rapid resolution to problems with concurrent care is possible. For example, Immediate Advocacy can resolve logistical issues with care, such as access to expected supplies or equipment. Within Livanta s Quality of Care Program, educational feedback is delivered to the provider regarding how care can be improved in future cases when a quality of care concern is confirmed. Likewise, cases in which a systemic issue is identified are referred to the state's local QIN-QIO to provide local technical assistance to the health care provider organization to address the underlying issues that may have led to the failure in care. Through the handling of appeals, EMTALA cases and utilization reviews, Livanta also protects beneficiary rights and the integrity of the Medicare Trust Fund by ensuring that Medicare pays for only health care services and items that are reasonable and medically necessary, and that these services are provided in the most appropriate setting. This also impacts the quality of care delivered. Any time a health care provider delivers care that is invasive but not medically necessary, there will be the risk of unnecessary harm to the patient. 18 P a g e

23 APPENDIX LIVANTA QIO AREA #5 STATE OF ALASKA 1) TOTAL # OF REVIEWS Review Type # of Reviews Percent of TOTAL Reviews Coding Validation (120 - HWDRG) % Coding Validation (All Other Selection Reasons) % Quality of Care Review (101 through Beneficiary Complaint) % Quality of Care Review (All Other Selection Reasons) % Utilization (158 - FI/MAC Referral for Readmission Review) % Utilization (All Other Selection Reasons) % Notice of Non-coverage (105 through Admission and Preadmission) % Notice of Non-coverage (118 - BIPA) % Notice of Non-coverage (117 - Grijalva) % Notice of Non-coverage (121 through Weichardt) % Notice of Non-coverage (111-Request for QIO Concurrence) % EMTALA 5 Day % EMTALA 60 Day % Total % A r e a 5 A l a s k a 19 P a g e

24 2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES BFCC-QIO 11 th SOW Annual Medical Services Report Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries 1. A419 - SEPSIS, UNSPECIFIED ORGANISM % SEPTICEMIA NOS % 3. J189 - PNEUMONIA, UNSPECIFIED ORGANISM % PNEUMONIA, ORGANISM NOS % 5. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W (ACUTE) % EXACERBATION LOC OSTEOARTH NOS-L/LEG % 7. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION % 8. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED % 9. M UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT KNEE % OBS CHR BRONC W(AC) EXAC % Total 2, % A r e a 5 A l a s k a 20 P a g e

25 3) BENEFICIARY DEMOGRAPHICS Demographics # of Beneficiaries Percent of Beneficiaries Sex/Gender Female % Male % Unknown % Total Race Asian % Black % Hispanic % North American Native % Other % Unknown % White % Total % Age Under % % % % % Total % A r e a 5 A l a s k a 21 P a g e

26 4) PROVIDER REVIEWS SETTINGS Setting # of Providers Percent of Providers 0: Acute Care Unit of an Inpatient Facility % 1: Distinct Psychiatric Facility % 2: Distinct Rehabilitation Facility % 3: Distinct Skilled Nursing Facility % 5: Clinic % 6: Distinct Dialysis Center Facility % 7: Dialysis Center Unit of Inpatient Facility % 8: Independent Based RHC % 9: Provider Based RHC % C: Free Standing Ambulatory Surgery Center % G: End Stage Renal Disease Unit % H: Home Health Agency % N: Critical Access Hospital % O: Setting Does Not Fit Into Any Other Existing Setting Code % Q: Long-Term Care Facility % R: Hospice % S: Psychiatric Unit of an Inpatient Facility % T: Rehabilitation Unit of an Inpatient Facility % U: Swing Bed Hospital Designation for Short-Term, Long-Term Care, and Rehabilitation Hospitals % Y: Federally Qualified Health Centers % Z: Swing Bed Designation for Critical Access Hospitals % Other % Total % A r e a 5 A l a s k a 22 P a g e

27 5) QUALITY OF CARE CONCERNS CONFIRMED Quality of Care ( C Category) PRAF Category Codes # of Concerns # of Concerns Confirmed Percent Confirmed Concerns # of Concerns Referred as Quality Improvement Initiatives (QII) C01: Apparently did not obtain pertinent history and/or findings from examination % 0 C02: Apparently did not make appropriate diagnoses and/or assessments % 0 C03: Apparently did not establish and/or develop an appropriate treatment plan for a defined problem or diagnosis which prompted this episode of care [excludes laboratory and/or imaging (see C06 or C09) and procedures (see C07 or C08) and consultations (see C13 and C14)] C04: Apparently did not carry out an established plan in a competent and/or timely fashion C05: Apparently did not appropriately assess and/or act on changes in clinical/other status results C06: Apparently did not appropriately assess and/or act on laboratory tests or imaging study results C07: Apparently did not establish adequate clinical justification for a procedure which carries patient risk and was performed C08: Apparently did not perform a procedure that was indicated (other than lab and imaging, see C09) C09: Apparently did not obtain appropriate laboratory tests and/or imaging studies C10: Apparently did not develop and initiate appropriate discharge, follow-up, and/or rehabilitation plans C11: Apparently did not demonstrate that the patient was ready for discharge C12: Apparently did not provide appropriate personnel and/or resources C13: Apparently did not order appropriate specialty consultation % % % % % % % % % % % 0 A r e a 5 A l a s k a 23 P a g e

28 Quality of Care ( C Category) PRAF Category Codes C14: Apparently specialty consultation process was not completed in a timely manner C15: Apparently did not effectively coordinate across disciplines C16: Apparently did not ensure a safe environment (medication errors, falls, pressure ulcers, transfusion reactions, nosocomial infection) C17: Apparently did not order/follow evidence-based practices C18: Apparently did not provide medical record documentation that impacts patient care C40: Apparently did not follow up on patient s non-compliance C99: Other quality concern not elsewhere classified # of Concerns BFCC-QIO 11 th SOW Annual Medical Services Report # of Concerns Confirmed Percent Confirmed Concerns # of Concerns Referred as Quality Improvement Initiatives (QII) % % % % % % % 0 Total % 0 A r e a 5 A l a s k a 24 P a g e

29 6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE Appeal Review by Notification Type # of Reviews of Total 105: Notice of Non-coverage FFS Preadmission Notice Concurrent Immediate Review % 106: Notice of Non-coverage FFS Preadmission Notice Non-immediate Review % 107: Notice of Non-coverage FFS Admission Notice Concurrent Immediate Review % 108: Notice of Non-coverage FFS Admission Notice Non-immediate Review % 111: Notice of Non-coverage Request for QIO Concurrence % 117: MA Appeal Review (CORF, HHA, SNF) % 118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) % 121: Notice of Non-coverage Continued Stay Notice Immediate Review - Attending Physician Concurs % 122: Notice of Non-coverage Continued Stay Notice Concurrent Nonimmediate Review % 123: Notice of Non-coverage Continued Stay Retrospective % 124: MA Notice of Non-coverage Continued Stay Notice Immediate Review - Attending Physician Concurs % Total % A r e a 5 A l a s k a 25 P a g e

30 7) REVIEWS BY GEOGRAPHIC AREA URBAN AND RURAL Table 7A: Appeals Reviews by Geographic Area Urban and Rural: Geographic Area # of Providers BFCC-QIO 11 th SOW Annual Medical Services Report Percent of Providers in State Percent of Providers in Service Area Appeal Reviews Urban % 89.64% Rural % 10.22% Unknown % 0.13% Total % % Table 7B: Quality of Care Reviews by Geographic Area Urban and Rural: Geographic Area # of Providers Percent of Providers in State Percent of Providers in Service Area Quality of Care Reviews Urban % 89.87% Rural % 9.97% Unknown % 0.16% Total % % 8) IMMEDIATE ADVOCACY REVIEWS # of Beneficiary Complaints # of Immediate Advocacy Reviews of Total Beneficiary Complaints Resolved by Immediate Advocacy Immediate Advocacy Reviews % A r e a 5 A l a s k a 26 P a g e

31 LIVANTA QIO AREA #5 STATE OF ARIZONA 1) TOTAL # OF REVIEWS Review Type # of Reviews Percent of TOTAL Reviews Coding Validation (120 - HWDRG) % Coding Validation (All Other Selection Reasons) % Quality of Care Review (101 through Beneficiary Complaint) % Quality of Care Review (All Other Selection Reasons) % Utilization (158 - FI/MAC Referral for Readmission Review) % Utilization (All Other Selection Reasons) 1, % Notice of Non-coverage (105 through Admission and Preadmission) % Notice of Non-coverage (118 - BIPA) % Notice of Non-coverage (117 - Grijalva) 1, % Notice of Non-coverage (121 through Weichardt) % Notice of Non-coverage (111-Request for QIO Concurrence) % EMTALA 5 Day % EMTALA 60 Day % Total 5, % A r e a 5 A r i z o n a 27 P a g e

32 2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES BFCC-QIO 11 th SOW Annual Medical Services Report Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries 1. A419 - SEPSIS, UNSPECIFIED ORGANISM 7, % 2. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 3, % SEPTICEMIA NOS 3, % 4. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION 2, % 5. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 2, % 6. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W (ACUTE) 2, % EXACERBATION 7. V REHABILITATION PROC NEC 2, % PNEUMONIA, ORGANISM NOS 1, % 9. M UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT KNEE 1, % 10. M UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT KNEE 1, % Total 29, % A r e a 5 A r i z o n a 28 P a g e

33 3) BENEFICIARY DEMOGRAPHICS Demographics # of Beneficiaries Percent of Beneficiaries Sex/Gender Female 2, % Male 1, % Unknown % Total 3, % Race Asian % Black % Hispanic % North American Native % Other % Unknown % White 3, % Total 3, % Age Under % % , % , % % Total 3, % A r e a 5 A r i z o n a 29 P a g e

34 4) PROVIDER REVIEWS SETTINGS Setting # of Providers Percent of Providers 0: Acute Care Unit of an Inpatient Facility % 1: Distinct Psychiatric Facility % 2: Distinct Rehabilitation Facility % 3: Distinct Skilled Nursing Facility % 5: Clinic % 6: Distinct Dialysis Center Facility % 7: Dialysis Center Unit of Inpatient Facility % 8: Independent Based RHC % 9: Provider Based RHC % C: Free Standing Ambulatory Surgery Center % G: End Stage Renal Disease Unit % H: Home Health Agency % N: Critical Access Hospital % O: Setting Does Not Fit Into Any Other Existing Setting Code % Q: Long-Term Care Facility % R: Hospice % S: Psychiatric Unit of an Inpatient Facility % T: Rehabilitation Unit of an Inpatient Facility % U: Swing Bed Hospital Designation for Short-Term, Long-Term Care, and Rehabilitation Hospitals % Y: Federally Qualified Health Centers % Z: Swing Bed Designation for Critical Access Hospitals % Other % Total % A r e a 5 A r i z o n a 30 P a g e

35 5) QUALITY OF CARE CONCERNS CONFIRMED Quality of Care ( C Category) PRAF Category Codes # of Concerns # of Concerns Confirmed Percent Confirmed Concerns # of Concerns Referred as Quality Improvement Initiatives (QII) C01: Apparently did not obtain pertinent history and/or findings from examination % 0 C02: Apparently did not make appropriate diagnoses and/or assessments % 3 C03: Apparently did not establish and/or develop an appropriate treatment plan for a defined problem or diagnosis which prompted this episode of care [excludes laboratory and/or imaging (see C06 or C09) and procedures (see C07 or C08) and consultations (see C13 and C14)] C04: Apparently did not carry out an established plan in a competent and/or timely fashion C05: Apparently did not appropriately assess and/or act on changes in clinical/other status results C06: Apparently did not appropriately assess and/or act on laboratory tests or imaging study results C07: Apparently did not establish adequate clinical justification for a procedure which carries patient risk and was performed C08: Apparently did not perform a procedure that was indicated (other than lab and imaging, see C09) C09: Apparently did not obtain appropriate laboratory tests and/or imaging studies C10: Apparently did not develop and initiate appropriate discharge, follow-up, and/or rehabilitation plans C11: Apparently did not demonstrate that the patient was ready for discharge C12: Apparently did not provide appropriate personnel and/or resources C13: Apparently did not order appropriate specialty consultation % % % % % % % % % % % 1 A r e a 5 A r i z o n a 31 P a g e

36 Quality of Care ( C Category) PRAF Category Codes C14: Apparently specialty consultation process was not completed in a timely manner C15: Apparently did not effectively coordinate across disciplines C16: Apparently did not ensure a safe environment (medication errors, falls, pressure ulcers, transfusion reactions, nosocomial infection) C17: Apparently did not order/follow evidence-based practices C18: Apparently did not provide medical record documentation that impacts patient care C40: Apparently did not follow up on patient s non-compliance C99: Other quality concern not elsewhere classified # of Concerns BFCC-QIO 11 th SOW Annual Medical Services Report # of Concerns Confirmed Percent Confirmed Concerns # of Concerns Referred as Quality Improvement Initiatives (QII) % % % % % % % 0 Total % 14 A r e a 5 A r i z o n a 32 P a g e

37 6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE Appeal Review by Notification Type # of Reviews of Total 105: Notice of Non-coverage FFS Preadmission Notice Concurrent Immediate Review % 106: Notice of Non-coverage FFS Preadmission Notice Non-immediate Review % 107: Notice of Non-coverage FFS Admission Notice Concurrent Immediate Review % 108: Notice of Non-coverage FFS Admission Notice Non-immediate Review % 111: Notice of Non-coverage Request for QIO Concurrence % 117: MA Appeal Review (CORF, HHA, SNF) 1, % 118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) % 121: Notice of Non-coverage Continued Stay Notice Immediate Review - Attending Physician Concurs % 122: Notice of Non-coverage Continued Stay Notice Concurrent Nonimmediate Review % 123: Notice of Non-coverage Continued Stay Retrospective % 124: MA Notice of Non-coverage Continued Stay Notice Immediate Review - Attending Physician Concurs % Total 2, % A r e a 5 A r i z o n a 33 P a g e

38 7) REVIEWS BY GEOGRAPHIC AREA URBAN AND RURAL Table 7A: Appeals Reviews by Geographic Area Urban and Rural: Geographic Area # of Providers BFCC-QIO 11 th SOW Annual Medical Services Report Percent of Providers in State Percent of Providers in Service Area Appeal Reviews Urban % 89.64% Rural % 10.22% Unknown % 0.13% Total % % Table 7B: Quality of Care Reviews by Geographic Area Urban and Rural: Geographic Area # of Providers Percent of Providers in State Percent of Providers in Service Area Quality of Care Reviews Urban % 89.87% Rural % 9.97% Unknown % 0.16% Total % % 8) IMMEDIATE ADVOCACY REVIEWS # of Beneficiary Complaints # of Immediate Advocacy Reviews of Total Beneficiary Complaints Resolved by Immediate Advocacy Immediate Advocacy Reviews % A r e a 5 A r i z o n a 34 P a g e

39 LIVANTA QIO AREA #5 STATE OF CALIFORNIA 1) TOTAL # OF REVIEWS Review Type # of Reviews Percent of TOTAL Reviews Coding Validation (120 - HWDRG) 3, % Coding Validation (All Other Selection Reasons) % Quality of Care Review (101 through Beneficiary Complaint) % Quality of Care Review (All Other Selection Reasons) % Utilization (158 - FI/MAC Referral for Readmission Review) % Utilization (All Other Selection Reasons) 12, % Notice of Non-coverage (105 through Admission and Preadmission) % Notice of Non-coverage (118 - BIPA) 4, % Notice of Non-coverage (117 - Grijalva) 8, % Notice of Non-coverage (121 through Weichardt) 7, % Notice of Non-coverage (111-Request for QIO Concurrence) % EMTALA 5 Day % EMTALA 60 Day % Total 37, % A r e a 5 C a l i f o r n i a 35 P a g e

40 2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES BFCC-QIO 11 th SOW Annual Medical Services Report Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries 1. A419 - SEPSIS, UNSPECIFIED ORGANISM 44, % SEPTICEMIA NOS 17, % 3. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 15, % 4. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 10, % 5. N390 - URINARY TRACT INFECTION, SITE NOT SPECIFIED 10, % 6. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W (ACUTE) 9, % EXACERBATION 7. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION 9, % 8. I639 - CEREBRAL INFARCTION, UNSPECIFIED 7, % 9. I ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART 6, % FAILURE 10. J690 - PNEUMONITIS DUE TO INHALATION OF FOOD AND VOMIT 6, % Total 139, % A r e a 5 C a l i f o r n i a 36 P a g e

41 3) BENEFICIARY DEMOGRAPHICS Demographics # of Beneficiaries Percent of Beneficiaries Sex/Gender Female 13, % Male 3, % Unknown % Total 23, % Race Asian 1, % Black 2, % Hispanic 1, % North American Native % Other % Unknown % White 17, % Total 23, % Age Under 65 3, % , % , % , % 91+ 2, % Total 23, % A r e a 5 C a l i f o r n i a 37 P a g e

42 4) PROVIDER REVIEWS SETTINGS Setting # of Providers Percent of Providers 0: Acute Care Unit of an Inpatient Facility % 1: Distinct Psychiatric Facility % 2: Distinct Rehabilitation Facility % 3: Distinct Skilled Nursing Facility % 5: Clinic % 6: Distinct Dialysis Center Facility % 7: Dialysis Center Unit of Inpatient Facility % 8: Independent Based RHC % 9: Provider Based RHC % C: Free Standing Ambulatory Surgery Center % G: End Stage Renal Disease Unit % H: Home Health Agency % N: Critical Access Hospital % O: Setting Does Not Fit Into Any Other Existing Setting Code % Q: Long-Term Care Facility % R: Hospice % S: Psychiatric Unit of an Inpatient Facility % T: Rehabilitation Unit of an Inpatient Facility % U: Swing Bed Hospital Designation for Short-Term, Long-Term Care, and Rehabilitation Hospitals % Y: Federally Qualified Health Centers % Z: Swing Bed Designation for Critical Access Hospitals % Other % Total 1, % A r e a 5 C a l i f o r n i a 38 P a g e

43 5) QUALITY OF CARE CONCERNS CONFIRMED Quality of Care ( C Category) PRAF Category Codes # of Concerns # of Concerns Confirmed Percent Confirmed Concerns # of Concerns Referred as Quality Improvement Initiatives (QII) C01: Apparently did not obtain pertinent history and/or findings from examination % 1 C02: Apparently did not make appropriate diagnoses and/or assessments % 22 C03: Apparently did not establish and/or develop an appropriate treatment plan for a defined problem or diagnosis which prompted this episode of care [excludes laboratory and/or imaging (see C06 or C09) and procedures (see C07 or C08) and consultations (see C13 and C14)] C04: Apparently did not carry out an established plan in a competent and/or timely fashion C05: Apparently did not appropriately assess and/or act on changes in clinical/other status results C06: Apparently did not appropriately assess and/or act on laboratory tests or imaging study results C07: Apparently did not establish adequate clinical justification for a procedure which carries patient risk and was performed C08: Apparently did not perform a procedure that was indicated (other than lab and imaging, see C09) C09: Apparently did not obtain appropriate laboratory tests and/or imaging studies C10: Apparently did not develop and initiate appropriate discharge, follow-up, and/or rehabilitation plans C11: Apparently did not demonstrate that the patient was ready for discharge C12: Apparently did not provide appropriate personnel and/or resources C13: Apparently did not order appropriate specialty consultation % % % % % % % % % % % 1 A r e a 5 C a l i f o r n i a 39 P a g e

44 Quality of Care ( C Category) PRAF Category Codes C14: Apparently specialty consultation process was not completed in a timely manner C15: Apparently did not effectively coordinate across disciplines C16: Apparently did not ensure a safe environment (medication errors, falls, pressure ulcers, transfusion reactions, nosocomial infection) C17: Apparently did not order/follow evidence-based practices C18: Apparently did not provide medical record documentation that impacts patient care C40: Apparently did not follow up on patient s non-compliance C99: Other quality concern not elsewhere classified # of Concerns BFCC-QIO 11 th SOW Annual Medical Services Report # of Concerns Confirmed Percent Confirmed Concerns # of Concerns Referred as Quality Improvement Initiatives (QII) % % % % % % % 18 Total 2, % 141 A r e a 5 C a l i f o r n i a 40 P a g e

45 6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE Appeal Review by Notification Type # of Reviews of Total 105: Notice of Non-coverage FFS Preadmission Notice Concurrent Immediate Review % 106: Notice of Non-coverage FFS Preadmission Notice Non-immediate Review % 107: Notice of Non-coverage FFS Admission Notice Concurrent Immediate Review % 108: Notice of Non-coverage FFS Admission Notice Non-immediate Review % 111: Notice of Non-coverage Request for QIO Concurrence % 117: MA Appeal Review (CORF, HHA, SNF) 7, % 118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 3, % 121: Notice of Non-coverage Continued Stay Notice Immediate Review - Attending Physician Concurs 2, % 122: Notice of Non-coverage Continued Stay Notice Concurrent Nonimmediate Review % 123: Notice of Non-coverage Continued Stay Retrospective % 124: MA Notice of Non-coverage Continued Stay Notice Immediate Review - Attending Physician Concurs 3, % Total 18, % A r e a 5 C a l i f o r n i a 41 P a g e

46 7) REVIEWS BY GEOGRAPHIC AREA URBAN AND RURAL Table 7A: Appeals Reviews by Geographic Area Urban and Rural: Geographic Area # of Providers BFCC-QIO 11 th SOW Annual Medical Services Report Percent of Providers in State Percent of Providers in Service Area Appeal Reviews Urban 1, % 89.64% Rural % 10.22% Unknown % 0.13% Total 1, % % Table 7B: Quality of Care Reviews by Geographic Area Urban and Rural: Geographic Area # of Providers Percent of Providers in State Percent of Providers in Service Area Quality of Care Reviews Urban % 89.87% Rural % 9.97% Unknown % 0.16% Total % % 8) IMMEDIATE ADVOCACY REVIEWS # of Beneficiary Complaints # of Immediate Advocacy Reviews of Total Beneficiary Complaints Resolved by Immediate Advocacy Immediate Advocacy Reviews 1, % A r e a 5 C a l i f o r n i a 42 P a g e

47 LIVANTA QIO AREA #5 STATE OF HAWAII 1) TOTAL # OF REVIEWS Review Type # of Reviews Percent of TOTAL Reviews Coding Validation (120 - HWDRG) % Coding Validation (All Other Selection Reasons) % Quality of Care Review (101 through Beneficiary Complaint) % Quality of Care Review (All Other Selection Reasons) % Utilization (158 - FI/MAC Referral for Readmission Review) % Utilization (All Other Selection Reasons) % Notice of Non-coverage (105 through Admission and Preadmission) % Notice of Non-coverage (118 - BIPA) % Notice of Non-coverage (117 - Grijalva) % Notice of Non-coverage (121 through Weichardt) % Notice of Non-coverage (111-Request for QIO Concurrence) % EMTALA 5 Day % EMTALA 60 Day % Total % A r e a 5 H a w a i i 43 P a g e