An Overview of BFCC-QIO Services for People with Medicare
What is this presentation about? You will learn about: 1. Free services for people with Medicare from Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) 2. When people with Medicare should contact their BFCC-QIO 2
What are BFCC-QIOs? Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) work with the Centers for Medicare & Medicaid Services (CMS) to help people with Medicare access their right to high quality health care. BFCC-QIO services Discharge appeals and service terminations Quality of care complaints Immediate Advocacy BFCC-QIO services are free of charge for Medicare beneficiaries. 3
Discharge Appeals and Service Termination Appeals As a person with Medicare, you can File a discharge appeal if you think you are being discharged too soon from a hospital. File a service termination appeal if you think skilled services at a skilled nursing facility, outpatient rehabilitation facility, home health agency, or a hospice are ending too soon. You can file these appeals by contacting the BFCC-QIO for your state. The BFCC-QIO will: Give you information so you can make an informed decision Tell you about your options Help you file an appeal 4
Steps to Filing an Appeal Step 1 Ste p 2 Step 3 Step 4 You (or your representative) contact the BFCC-QIO. The BFCC-QIO requests medical records. The medical record is reviewed by a peer reviewer. You and the healthcare provider are notified of the decision. 5
What is a quality of care complaint? A quality of care complaint is a formal Medicare complaint you or your representative can submit if you have a concern about the quality of care you received. Examples of questions and concerns BFCC-QIOs can help you with: Did I get the right medicine? Did I get the right dose of the medicine? Did I get a surgery that I didn t need? Did I get a diagnostic test that I didn t need? My conditioned changed, and it was not treated. My diagnosis was not correct. I did not get enough discharge information when I was discharged. 6
Steps to Filing a Quality of Care Complaint Step 1 You (or your representative) contact the BFCC-QIO. Step 2 Step 3 Step 4 Step 5 The BFCC-QIO will decide if the concern would be better handled using Immediate Advocacy, an informal complaint resolution process. If a formal review is suggested, the BFCC-QIO will help you (or your representative) do the paperwork. A physician reviewer will review your medical record to decide if the right care was provided. The BFCC-QIO will notify you and the provider of the review decision (phone call and letter). 7
Beneficiary Complaint: Reconsideration Stage If you are unhappy with the BFCC-QIO s final decision, you may ask that another physician review the medical record. You need to make this request within three days of getting notified by phone. This process is called Reconsideration. The BFCC-QIO will notify you by phone and in writing of the final decision within five days of getting the request for Reconsideration. 8
Outcomes of Quality of Care Complaints If the quality of care review finds that the right care was not provided, the BFCC-QIO may: Require that the provider take a class or have more training. Look at more medical records of other people with Medicare to see if there are other quality of care concerns. Forward the concern to a Quality Innovation Network QIO (QIN- QIO). QIN-QIOs work with providers to help them with quality improvement activities. 9
Immediate Advocacy If you are a person with Medicare, you can ask for a process called Immediate Advocacy to quickly resolve concerns related to medical care you received. This process can relate also to services that accompany medical care. Examples of concerns that Immediate Advocacy can be used for include: The hospital staff won t answer my questions. My doctor ordered a wheelchair, but I have not gotten it yet. I need to refill my prescription but can t get an appointment to see my doctor. 10
Steps to Receive Immediate Advocacy STEP 1 You (or your representative) contact the BFCC-QIO. STEP 2 STEP 3 The process begins when you or your representative verbally agree to Immediate Advocacy. The BFCC-QIO immediately contacts the provider, insurance, or medical equipment company on your behalf to resolve the complaint. Immediate Advocacy may be stopped at any time, at which time the BFCC-QIO will let you know about your right to file a written quality of care complaint. 11
BFCC-QIO Contact Information Two BFCC-QIOs, KEPRO and Livanta, serve all 50 states, the District of Columbia, and three territories. http://qioprogram.org/contact-zones 12
Thank you! Questions? Email bfcc.ncc@bfccncc.hcqis.org Publication No. BFCCNCC-179-11/2017. This material was prepared by KEPRO, the Beneficiary and Family Centered Care National Coordinating Center under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 13