QIO Program. BFCC-QIO 11th SOW Annual Medical Services Report - D. 4 Deliverable Contract Year 3 Area 4

Transcription

1 QIO Program BFCC-QIO 11th SOW Annual Medical Services Report - D. 4 Deliverable Contract Year 3 Area 4

2 BFCC-QIO 11TH SOW ANNUAL MEDICAL SERVICES REPORT D.4 DELIVERABLE

3 TABLE OF CONTENTS Introduction... 6 Annual Report Body: ) Total Reviews ) Top 10 Principal Medical Diagnoses: ) Provider Reviews Settings: ) Quality of Care and Quality Improvement Initiatives ) Discharge/Service Terminations ) 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 BFCC-QIO Area #4 State of Iowa ) Total Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care and Quality Improvement Initiatives ) 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 BFCC-QIO Area #4 State of Illinois ) Total Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics Page 2

4 4) Provider Reviews Settings ) Quality of Care and Quality Improvement Initiatives ) 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 BFCC-QIO Area #4 State of Indiana ) Total Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care and Quality Improvement Initiatives ) 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 BFCC-QIO Area #4 State of Kansas ) Total Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care and Quality Improvement Initiatives ) 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 BFCC-QIO Area #4 State of Michigan ) Total Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care and Quality Improvement Initiatives Page 3

5 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 BFCC-QIO Area #4 State of Minnesota ) Total Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care and Quality Improvement Initiatives ) 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 BFCC-QIO Area #4 State of Missouri ) Total Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care and Quality Improvement Initiatives ) 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 BFCC-QIO Area #4 State of Nebraska ) Total Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care and Quality Improvement Initiatives ) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by Notification Type ) Reviews by Geographic Area Urban and Rural Page 4

6 8) Immediate Advocacy Reviews BFCC-QIO Area #4 State of Ohio ) Total Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care and Quality Improvement Initiatives ) 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 BFCC-QIO Area #4 State of Wisconsin ) Total Reviews ) Top 10 Principal Medical Diagnoses ) Beneficiary Demographics ) Provider Reviews Settings ) Quality of Care and Quality Improvement Initiatives ) 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 Page 5

7 Introduction BFCC-QIO 11 th SOW Annual Medical Services Report D.4 Deliverable Improving the quality, safety, and value of the care the Medicare beneficiary receives through the Medicare program is what the Quality Improvement Organization (QIO) Program is all about. QIOs provide resources to help beneficiaries become more confident in making health care decisions and actively managing their health. Beneficiary and Family Centered Care QIOs (BFCC-QIOs), such as KEPRO, are also here to help when the beneficiary and/or their family members have a complaint about clinical quality or want to appeal a health care provider s decision to discontinue services or discharge the beneficiary from the hospital. It s important to know how QIOs, such as KEPRO, work with you, your family, and your health care team. Medicare has strict policies about our processes, designed to protect a Medicare beneficiary s privacy and give him/her objective information about the care he/she received. KEPRO is the Centers for Medicare & Medicaid Services (CMS) designated BFCC-QIO for Area 4, which covers the following states: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio, and Wisconsin. The QIO Program is an integral part of the U.S. Department of Health and Human Services National Quality Strategy and the CMS Quality Strategy. Within this report, you will find data which reflects the work KEPRO has completed within the third year of its BFCC-QIO contract. In the first portion of this report, you will find global or overall data with state-specific data to follow in the Appendix section of the report. Page 6

8 ANNUAL REPORT BODY: 1) TOTAL NUMBER OF REVIEWS The below data reflects the total number of medical record reviews completed for Area 4. The BFCC-QIO has review authority for a number of different situations. These include: Beneficiaries or their appointed representatives who have concerns related to the quality of provided health care services by either a facility or physician. Beneficiaries or their representatives who are appealing a pending hospital discharge or the discontinuation of skilled services such as physical therapy. Hospitals requesting a higher reimbursement from Medicare. All of these claims are sent to the BFCC- QIO for coding validation and medical necessity review. Potential EMTALA violations In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual's ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented. Review Type Reviews Total Reviews Coding Validation (120 - HWDRG) 6, % 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) 14, % Notice of Non-coverage (105 through Admission and Preadmission) % Notice of Non-coverage (118 - BIPA) 8, % Notice of Non-coverage (117 - Grijalva) 26, % Notice of Non-coverage (121 through Weichardt) 3, % Notice of Non-coverage (111 - Request for QIO Concurrence) % Emergency Medical Treatment & Labor Act (EMTALA) 5 Day % EMTALA 60 Day % Total 60, % Page 7

9 2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES: BFCC-QIO 11 th SOW Annual Medical Services Report D.4 Deliverable The below data reflect the top 10 diagnoses associated with Medicare claims for Area 4. Top 10 Medical Diagnoses Beneficiaries Beneficiaries 1. A419 - SEPSIS, UNSPECIFIED ORGANISM 138, % 2. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 59, % 3. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 56, % 4. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W (ACUTE) EXACERBATION 51, % 5. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION 46, % 6. N390 - URINARY TRACT INFECTION, SITE NOT SPECIFIED 41, % 7. I130 - HYP HRT & CHR KDNY DIS W HRT FAIL AND STG 1-4/UNSP 39, % CHR KDNY 8. M UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT KNEE 38, % 9. M UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT KNEE 35, % 10. J440 - CHRONIC OBSTRUCTIVE PULMON DISEASE W ACUTE LOWER RESP INFCT 29, % Total 536, % 3) PROVIDER REVIEWS SETTINGS: The below data reflects the location associated with the beneficiary s complaint. Setting Providers Providers 0: Acute Care Unit of an Inpatient Facility % 1: Distinct Psychiatric Facility % 2: Distinct Rehabilitation Facility % 3: Distinct Skilled Nursing Facility 2, % 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 % Page 8

10 Y: Federally Qualified Health Centers % Z: Swing Bed Designation for Critical Access Hospitals % Other % Total 4, % 4) QUALITY OF CARE CONCERNS CONFIRMED AND QUALITY IMPROVEMENT INITIATIVES The below data reflects the category of quality of care concerns identified during medical record reviews along with the corresponding outcome. A Quality of Care review is conducted by the BFCC-QIO to determine whether the quality of services provided to beneficiaries was consistent with professionally recognized standards of health care. A Quality of Care review can either be initiated by a Medicare beneficiary or his/her appointed representative or referred to the BFCC-QIO from another agency such as the Office of Medicare Ombudsmen and/or Congress, etc. KEPRO, in keeping with CMS directions, has referred all confirmed quality of care concerns, which appear to be systemic in nature and appropriate for quality improvement activities, to the appropriate Quality Innovation Network QIO (QIN-QIO) for follow-up. For confirmed concerns that may be amenable to a different approach to health care or related to documentation, KEPRO would retain those concerns and work directly with the health care provider and/or practitioner. The below data reflects the total number of concerns referred to the QIN- QIO and not those retained by KEPRO in order to provide technical assistance. Quality of Care ( C Category) PRAF Category Codes C01: Apparently did not obtain pertinent history and/or findings from examination C02: Apparently did not make appropriate diagnoses and/or assessments 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 Number of Percent % % Referred as Quality Improvement Initiatives (QII) % % % % Page 9

11 Number of Percent Referred as Quality Improvement Initiatives (QII) Quality of Care ( C Category) PRAF Category Codes 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 % 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 % 20 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 noncompliance % C99: Other quality concern not elsewhere classified % Total 1, % 28 Quality of Care Referred for Quality Improvement Initiatives (QIIs) Referred for QII Quality of Care Referred for QII % Page 10

12 5) DISCHARGE/SERVICE TERMINATIONS The below data reflects the discharge location of beneficiaries which are linked to hospital discharge appeal reviews. Note: Data contained in this table represent discharge/service termination reviews from August 1, 2016, through April 30, A shortened time frame is necessary to allow for maturity of claims data, which are the source of Discharge Status for these cases. Discharge Status Beneficiaries Beneficiaries 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) % 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 % 50: Hospice - home % 51: Hospice - medical facility % 61: Discharged/transferred within this institution to a hospital-based, Medicareapproved 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 1, % Page 11

13 6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE The below data reflect the number of appeal reviews and the percentage of reviews, for each outcome, in which the physician reviewer either agreed or disagreed with the discharge or discontinuation of skilled services decision. Reviews Physician Reviewer Disagreed with Discharge (%) Physician Reviewer Agreed with 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 % 0.00% 107: Notice of Non-coverage FFS Admission Notice Concurrent Immediate Review % 54.55% 108: Notice of Non-coverage FFS Admission Notice Nonimmediate Review % 0.00% 111: Notice of Non-coverage Request for BFCC-QIO Concurrence % % 117: MA Appeal Review (CORF, HHA, SNF) 25, % 71.84% 118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 8, % 83.61% 121: Notice of Non-coverage Continued Stay Notice Immediate Review - Attending Physician Concurs 2, % 94.58% 122: Notice of Non-coverage Continued Stay Notice Concurrent Non-immediate Review % 0.00% 123: Notice of Non-coverage Continued Stay Retrospective % % 124: MA Notice of Non-coverage Continued Stay Notice Immediate Review - Attending Physician Concurs 1, % 93.02% Total 37, % 76.50% 7) EVIDENCE USED IN DECISION-MAKING The table that follows describes the one to two most common types of evidence or standards of care used to support KEPRO Review Analysts assessments and aid in formatting questions raised to the Peer Reviewer for his/her clinical decisions for Medical Necessity/Utilization Review and Appeals. For the Quality of Care reviews, KEPRO has provided one to three most highly utilized types of evidence/standards of care to support KEPRO Review Analysts assessments and aid in formatting questions raised to the Peer Reviewer for his/her clinical decisions. A brief statement of the rationale for selecting the specific evidence or standards of care is also included. Page 12

14 Diagnostic Review Type Categories Quality of Care Pneumonia Heart Failure Pressure Ulcers Evidence/ Standards of Care Used CMS Pneumonia indicators (PN 2-7) UpToDate American College of Cardiology (ACC); CMS Heart Failure indicators (HF 1-3) UpToDate AHRQ website; Wound, Ostomy & Continence Nursing website ( CMS Hospital- Acquired Conditions & Patient Safety Indicators (PSI-03 & PSI-90 Composite Measure) UpToDate Rationale for Evidence/Standard of Care Selected CMS guidelines for the management of patients with community-acquired pneumonia (CAP) address basic aspects of preventive care and treatment for CAP. The guidelines emphasize the importance of vaccination as well as the need for appropriate and timely antimicrobial therapy. Adherence to guidelines is associated with improved patient outcomes. UpToDate is the premier evidence-based clinical decision support resource, trusted worldwide by health care practitioners to help them make the right decisions at the point of care. It is proven to change the way clinicians practice medicine and is the only resource of its kind associated with improved outcomes. ACC s guidelines for the management of patients with heart failure address aspects of care that when followed are associated with improved patient outcomes. UpToDate is the premier evidence-based clinical decision support resource, trusted worldwide by health care practitioners to help them make the right decisions at the point of care. It is proven to change the way clinicians practice medicine and is the only resource of its kind associated with improved outcomes. The Agency for Health care Research and Quality (AHRQ) remains an excellent online resource for the identification of standards of care and practice guidelines. WOCN provides nursing guidelines for staging and care of pressure ulcers. CMS Patient Safety Indicators (PSI) are measurements of quality of patient care during hospitalization and were developed by AHRQ after years of research and analysis. AHRQ developed the PSIs to help hospitals identify potentially preventable adverse events or serious medical errors. UpToDate is the premier evidence-based clinical Page 13

15 Acute Myocardial Infarction Urinary Tract Infection American College of Cardiology Acute Myocardial Infarction Guidelines; CMS Acute Myocardial Infarction indicators (AMI 2-10) UpToDate HAI-CAUTI (f/k/a HAC-7) UpToDate decision support resource, trusted worldwide by health care practitioners to help them make the right decisions at the point of care. It is proven to change the way clinicians practice medicine and is the only resource of its kind associated with improved outcomes. ACC s guidelines for the management of patients with acute myocardial infarction address aspects of care that when followed are associated with improved patient outcomes. UpToDate is the premier evidence-based clinical decision support resource, trusted worldwide by health care practitioners to help them make the right decisions at the point of care. It is proven to change the way clinicians practice medicine and is the only resource of its kind associated with improved outcomes. CMS PSIs are measurements of quality of patient care during hospitalization and were developed by AHRQ after years of research and analysis. AHRQ developed the PSIs to help hospitals identify potentially preventable adverse events or serious medical errors. Sepsis Adverse Drug Events Institute for Health care Improvement (IHI) UpToDate CMS Hospital- Acquired Conditions & Patient Safety Indicators (PSI-03 & UpToDate is the premier evidence-based clinical decision support resource, trusted worldwide by health care practitioners to help them make the right decisions at the point of care. It is proven to change the way clinicians practice medicine and is the only resource of its kind associated with improved outcomes. IHI developed sepsis indicators and guidelines for the identification and treatment of sepsis. Adherence to such guidelines has improved patient outcomes. UpToDate is the premier evidence-based clinical decision support resource, trusted worldwide by health care practitioners to help them make the right decisions at the point of care. It is proven to change the way clinicians practice medicine, and is the only resource of its kind associated with improved outcomes. CMS PSIs are measurements of quality of patient care during hospitalization and were developed by AHRQ after years of research and analysis. AHRQ developed the PSIs to help hospitals Page 14

16 Medical Necessity/ Utilization Review Appeals Falls Patient Trauma Surgical complications InterQual & CMS Two- Midnight Rule Benchmark criteria PSI-90 Composite Measure) CMS Hospital- Acquired Conditions & Patient Safety Indicators (PSI-03 & PSI-90 Composite Measure) CMS Hospital- Acquired Conditions & Patient Safety Indicators (PSI-03 & PSI-90 Composite Measure) KEPRO s Generic Quality Screening Tool InterQual & CMS Two-Midnight Rule Benchmark criteria National Coverage Determination Guidelines; JIMMO settlement language and guidelines; and InterQual and CMS Two Midnight Rule Benchmark identify potentially preventable adverse events or serious medical errors. CMS PSIs are measurements of quality of patient care during hospitalization and were developed by AHRQ after years of research and analysis. AHRQ developed the PSIs to help hospitals identify potentially preventable adverse events or serious medical errors. CMS PSIs are measurements of quality of patient care during hospitalization and were developed by AHRQ after years of research and analysis. AHRQ developed the PSIs to help hospitals identify potentially preventable adverse events or serious medical errors. KEPRO developed a generic quality screening tool based upon generally recognized standards of care, for example: state-specific reportable events and Joint Commission reportable events. Specific questions are found on this tool, which ask about surgical complications. InterQual - Assess the safest and most efficient care level based on severity of illness, comorbidities and complications, and the intensity of services being delivered. Its criteria cover more than 95% of admission reasons for any level of care. Under the final CMS Two-Midnight Rule, surgical procedures, diagnostic tests, and other treatments (in addition to services designated as inpatient-only) are generally appropriate for inpatient hospital admission and payment under Medicare Part A when the physician expects the beneficiary to require a stay that crosses at least two midnights and admits the beneficiary to the hospital based upon that expectation. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National coverage determinations (NCDs) are made through an evidence-based process. Page 15

17 8) REVIEWS BY GEOGRAPHIC AREA In tables 8A-B, KEPRO has provided the count and percent by rural vs. urban geographical locations for Health Service Providers (HSPs) associated with a completed QIO review. Table 8A: Appeal Reviews by Geographic Area Urban and Rural: Geographic Area Providers Providers in Service Area Urban 2, % Rural 1, % Unknown % Total 3, % Table 8B: Quality of Care Reviews by Geographic Area Urban and Rural: Geographic Area Providers Providers in Service Area Urban % Rural % Unknown % Total % 9) OUTREACH AND COLLABORATION WITH BENEFICIARIES In Area 4, KEPRO has joined in on a collaborative partnership with several Ohio agencies working with the Medicare population. Led by the Ohio Senior Health Insurance Information Program (OSHIIP), these monthly Medicare Partner meetings include stakeholders such as Senior Medicare Patrol (SMP), Office of the State Long-term Care Ombudsman, Heath Services Advisory Group (Ohio s Quality Innovation Network QIO), CGS Administrators (Ohio s Medicare Administrative Contractor), and the Social Security Administration. Participation in this group allows us to consistently update our stakeholders and provide them with important resources and materials that they can then distribute to beneficiaries and providers. Furthermore, as a result of KEPRO s strong relationship with OSHIIP, we have been invited to present information on our services numerous times to staff and volunteers across the state, which has the potential to reach over 350,000 Medicare beneficiaries. 10) IMMEDIATE ADVOCACY REVIEWS The below data reflects the number of beneficiary complaints resolved through the use of Immediate Advocacy. Based on the nature of the concern(s) raised by the beneficiary, KEPRO staff members may recommend the use of Immediate Advocacy. Immediate Advocacy is an informal process used to quickly resolve an oral or verbal complaint. In this process, KEPRO makes immediate/direct contact with a provider and/or practitioner for the beneficiary. The KEPRO staff member will summarize what Immediate Advocacy involves for the beneficiary and obtain the beneficiary s oral consent to participate in Immediate Advocacy before proceeding. Page 16

18 Immediate Total Beneficiary Complaints Beneficiary Complaints Advocacy Reviews Resolved by Immediate Advocacy % 11) EXAMPLE/SUCCESS STORY a.) A Medicare beneficiary contacted the BFCC-QIO with concerns about his ostomy supplies. He had undergone an ileostomy procedure and was receiving home health care. An order was put in two weeks earlier for the supplies, and he had not yet received them. He had not had a clean bag in eight days. He contacted the BFCC-QIO for assistance. The Intake Specialist set up a conference call with the durable medical equipment (DME) provider and the beneficiary. The home health agency had sent in an order for the supplies that day. The DME provider stated that they would send out an urgent sample request that afternoon. She would then verify the insurance and get the doctor s signature and send the rest of the supplies out marked as urgent. The Intake Specialist followed up with the beneficiary, and he had received all of his supplies. She also contacted the home health agency to see what had caused the delay. The agency stated that there had been some confusion about the beneficiary s coverage, which had caused a problem with the supplier. The agency representative stated that she would be contacting the beneficiary to go over his concerns. b.) A Medicare beneficiary contacted the BFCC-QIO with concerns about her discharge plan. She had a hernia repair and was discharged to home with a non-functioning wound vac. During the night, the staples came out of the wound, and it was now an open wound. She stated that after a home health evaluation, it was determined that she could not qualify because she was not completely homebound. However, she felt that due to the current circumstances, she should qualify. The Intake Specialist agreed to contact the home health agency on her behalf. The Intake Specialist contacted the Director at the home health agency. The Intake Specialist told the Director that the beneficiary was only out of the house once a week to get groceries, and that was difficult for her. The Director stated that she would reach out to the beneficiary to verify her homebound status. She stated that if the beneficiary qualified, they would start home health. If not, they would set her up for outpatient services. The Intake Specialist received a message from the Director several days later. They did admit the beneficiary for wound care services with the home health agency. She felt that the beneficiary did meet the criteria for being homebound. The Intake Specialist then contacted the beneficiary who expressed that this would not have happened without the phone call to the BFCC-QIO. c.) A Medicare beneficiary contacted the BFCC-QIO with concerns about her care at the hospital. She had been experiencing abdominal pain, and the medical staff was discussing surgery. She had not received any food since being at the facility. The staff wanted her to take antibiotics, but she was concerned about doing that on an empty stomach. She requested that the Intake Specialist intervene to find out her plan of care. Page 17

19 The Intake Specialist left a message with the facility and received a voic from the Assistant Quality Director. She stated that the beneficiary was on a clear liquid diet because she had a small bowel obstruction. The surgeon also came in to speak with the beneficiary about the surgery. The Intake Specialist then contacted the beneficiary. The beneficiary stated that her procedure had been delayed due to her infection, but she was appreciative of the intervention by the Intake Specialist. She felt that staff had come in to address her concerns because of the call by the Intake Specialist. Because her procedure was delayed, her diet was changed. She would be in the hospital for a few more days on antibiotics, and her surgery would be scheduled as an outpatient. The Intake Specialist then received a voic from the facility stating that the beneficiary liked to call KEPRO because they are the only people that get things done. 12) BENEFICIARY HELPLINE STATISTICS The below data reflect the total number of telephone calls received and processed for Area4. Beneficiary Helpline Report Total Per Category Total Calls Received 166,128 Total Calls Answered 154,231 Total Abandoned Calls 6,995 Average Length of Call Wait Times 00:01:06 Calls Transferred by Medicare 0 CONCLUSION KEPRO s outcomes and findings for year three of this CMS contract outline the daily work performed during the pursuit of care improvements provided to the individual Medicare beneficiary. These reviews provide solid data that can be extrapolated to improve the quality of provider care throughout the system based upon these individual s experiences as a part of the overall system. Page 18

20 APPENDIX BFCC-QIO AREA #4 STATE OF IOWA 1) TOTAL NUMBER OF REVIEWS Review Type Reviews 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 1, % 2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES Top 10 Medical Diagnoses Beneficiaries Beneficiaries 1. A419 - SEPSIS, UNSPECIFIED ORGANISM 6, % 2. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 4, % 3. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W (ACUTE) 2, % EXACERBATION 4. M UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT KNEE 2, % 5. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 2, % 6. M UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT KNEE 2, % 7. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION 2, % 8. N390 - URINARY TRACT INFECTION, SITE NOT SPECIFIED 2, % 9. I130 - HYP HRT & CHR KDNY DIS W HRT FAIL AND STG 1-4/UNSP 1, % CHR KDNY 10. Z ENCOUNTER FOR OTHER SPECIFIED AFTERCARE 1, % Total 28, % 3) BENEFICIARY DEMOGRAPHICS Demographics Beneficiaries Beneficiaries Sex/Gender Female % Page 19

21 Demographics Beneficiaries Beneficiaries Male % Unknown % Total 1, % Race Asian % Black % Hispanic % North American Native % Other % Unknown % White 1, % Total 1, % Age Under % % % % % Total 1, % 4) PROVIDER REVIEWS SETTINGS Setting Providers 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 % Page 20

22 Setting Providers Providers Z: Swing Bed Designation for Critical Access Hospitals % Other % Total % 5) QUALITY OF CARE CONCERNS CONFIRMED AND QUALITY IMPROVEMENT INITIATIVES Quality of Care ( C Category) PRAF Category Codes C01: Apparently did not obtain pertinent history and/or findings from examination C02: Apparently did not make appropriate diagnoses and/or assessments 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 Number of Percent % % % % % Referred as Quality Improvement Initiatives (QII) % % % % % Page 21

23 Number of Percent Referred as Quality Improvement Initiatives (QII) 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 noncompliance C99: Other quality concern not elsewhere classified % Total % 2 6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE Appeal Reviews by Notification Type Reviews Percent 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 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 % Total % Page 22

24 7) REVIEWS BY GEOGRAPHIC AREA URBAN AND RURAL Table 7A: Appeal Reviews by Geographic Area Urban and Rural: BFCC-QIO 11 th SOW Annual Medical Services Report D.4 Deliverable Geographic Area Providers Providers in State Providers in Service Area Urban % 72.08% Rural % 27.77% Unknown % 0.15% Total % % Table 7B: Quality of Care Reviews by Geographic Area Urban and Rural: Geographic Area Providers Providers in State Providers in Service Area Urban % 83.96% Rural % 16.04% Unknown % 0.00% Total % % 8) IMMEDIATE ADVOCACY REVIEWS Beneficiary Immediate Total Beneficiary Complaints Complaints Advocacy Reviews Resolved by Immediate Advocacy % Page 23

25 BFCC-QIO AREA #4 STATE OF ILLINOIS 1) TOTAL NUMBER OF REVIEWS BFCC-QIO 11 th SOW Annual Medical Services Report D.4 Deliverable Review Type Reviews 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) 2, % Notice of Non-coverage (105 through Admission and Preadmission) % Notice of Non-coverage (118 - BIPA) 1, % Notice of Non-coverage (117 - Grijalva) 3, % Notice of Non-coverage (121 through Weichardt) % Notice of Non-coverage (111 - Request for QIO Concurrence) % EMTALA 5 Day % EMTALA 60 Day % Total 9, % 2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES Top 10 Medical Diagnoses Beneficiaries Beneficiaries 1. A419 - SEPSIS, UNSPECIFIED ORGANISM 25, % 2. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 11, % 3. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 10, % 4. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W (ACUTE) EXACERBATION 9, % 5. N390 - URINARY TRACT INFECTION, SITE NOT SPECIFIED 8, % 6. I130 - HYP HRT & CHR KDNY DIS W HRT FAIL AND STG 1-4/UNSP CHR KDNY 8, % 7. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION 7, % 8. M UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT KNEE 6, % 9. J440 - CHRONIC OBSTRUCTIVE PULMON DISEASE W ACUTE LOWER RESP INFCT 5, % 10. M UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT KNEE 5, % Total 100, % 3) BENEFICIARY DEMOGRAPHICS Demographics Beneficiaries Beneficiaries Sex/Gender Female 4, % Male 3, % Page 24

26 Demographics Beneficiaries Beneficiaries Unknown % Total 8, % Race Asian % Black 1, % Hispanic % North American Native % Other % Unknown % White 6, % Total 8, % Age Under % , % , % , % 91+ 1, % Total 8, % 4) PROVIDER REVIEWS SETTINGS Setting Providers 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 % Page 25

27 Setting Providers Providers Other % Total % 5) QUALITY OF CARE CONCERNS CONFIRMED AND QUALITY IMPROVEMENT INITIATIVES Quality of Care ( C Category) PRAF Category Codes C01: Apparently did not obtain pertinent history and/or findings from examination C02: Apparently did not make appropriate diagnoses and/or assessments 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 C14: Apparently specialty consultation process was not completed in a timely manner Number of Percent % % % % Referred as Quality Improvement Initiatives (QII) % % % % % % % % % Page 26

28 Number of Percent Referred as Quality Improvement Initiatives (QII) Quality of Care ( C Category) PRAF Category Codes C15: Apparently did not effectively coordinate across disciplines % C16: Apparently did not ensure a safe environment (medication errors, falls, pressure ulcers, transfusion % 5 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 noncompliance C99: Other quality concern not elsewhere classified % Total % 5 6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE Appeal Reviews by Notification Type Reviews Percent 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) 3, % 118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 1, % 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 % Total 5, % Page 27

29 7) REVIEWS BY GEOGRAPHIC AREA URBAN AND RURAL Table 7A: Appeal Reviews by Geographic Area Urban and Rural: BFCC-QIO 11 th SOW Annual Medical Services Report D.4 Deliverable Geographic Area Providers Providers in State Providers in Service Area Urban % 72.08% Rural % 27.77% Unknown % 0.15% Total % % Table 7B: Quality of Care Reviews by Geographic Area Urban and Rural: Geographic Area Providers Providers in State Providers in Service Area Urban % 83.96% Rural % 16.04% Unknown % 0.00% Total % % 8) IMMEDIATE ADVOCACY REVIEWS Beneficiary Immediate Total Beneficiary Complaints Complaints Advocacy Reviews Resolved by Immediate Advocacy % Page 28

30 BFCC-QIO AREA #4 STATE OF INDIANA 1) TOTAL NUMBER OF REVIEWS BFCC-QIO 11 th SOW Annual Medical Services Report D.4 Deliverable Review Type Reviews 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) 3, % Notice of Non-coverage (121 through Weichardt) % Notice of Non-coverage (111 - Request for QIO Concurrence) % EMTALA 5 Day % EMTALA 60 Day % Total 6, % 2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES Top 10 Medical Diagnoses Beneficiaries Beneficiaries 1. A419 - SEPSIS, UNSPECIFIED ORGANISM 15, % 2. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W (ACUTE) EXACERBATION 6, % 3. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 6, % 4. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 6, % 5. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION 5, % 6. N390 - URINARY TRACT INFECTION, SITE NOT SPECIFIED 4, % 7. J440 - CHRONIC OBSTRUCTIVE PULMON DISEASE W ACUTE LOWER RESP INFCT 4, % 8. I130 - HYP HRT & CHR KDNY DIS W HRT FAIL AND STG 1-4/UNSP CHR KDNY 4, % 9. M UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT KNEE 3, % 10. M UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT KNEE 3, % Total 62, % 3) BENEFICIARY DEMOGRAPHICS Demographics Beneficiaries Beneficiaries Sex/Gender Female 3, % Male 2, % Page 29