As you may know, the Centers for Medicare & Medicaid Services (CMS) is restructuring the
Quality Improvement Organization (QIO) Program, effective August 1, 2014. The QIO Program is an integral
part of the U.S. Department of Health and Human Services’ national quality
strategy for providing better care, better health at lower costs, and providing
“boots on the ground” technical assistance through a national network of
independent organizations working to improve care delivery at the community
level. The updated approach to improving care will allow for greater
efficiencies across the program, eliminate any perceived conflicts of interest
and will continue to emphasize the need for greater patient-centered care in
support of the needs of Medicare beneficiaries.
New Contact for Medicare Coverage Appeals and
Quality of Care Concerns
The restructuring
of the QIO Program separates medical case review and monitoring activities from the
traditional quality improvement activities of QIOs, creating two separate structures:
•
Medical case review – to be performed by
Beneficiary and Family Centered Care Quality Improvement Organizations
(BFCC-QIO)
•
Quality improvement initiatives and technical
assistance – to be performed by Quality Innovation Network Quality Improvement
Organizations (QIN-QIO)
These contracts cannot be held by the same organization and
CFMC has chosen to pursue the quality improvement work as a QIN-QIO. We will
continue to perform clinical review work, including the Medicare appeal reviews
until July 31, 2014.
In early May, CMS awarded the BFCC-QIO contracts to
Livanta, LLC, located in Annapolis Junction, Maryland and KEPRO, located in
Seven Hills Ohio. These contractors will be responsible for conducting case review
functions such as complaint reviews, quality of care reviews, discharge
appeals, higher weighted diagnostic related groups (DRG) requests and Emergency
Medical Treatment and Active Labor Act (EMTALA) reviews.
Beginning August 1, 2014, Colorado hospitals,
hospital swing beds, skilled nursing facilities, home health agencies, hospice
agencies, and comprehensive outpatient rehabilitation facilities must contact KEPRO, the new BFCC-QIO that will serve Colorado, toll-free at 1-844-430-9504 for all appeal requests
and Quality of Care concerns. All outstanding Higher-Weighted DRG medical
record requests after the above date should be mailed to:
KEPRO
Rock Run Center
5700 Lombardo Center, Suite 100
Seven Hills, Ohio 44131
Likewise, beneficiaries who have a concern about the quality of
care they have received from a Medicare certified setting such as a physician’s
office or settings such as those listed above for appeals, will also have a new
point of contact.
Steps You Will
Need to Take
•
Update all copies of the Notice of Non-Coverage
forms which inform beneficiaries that Medicare may stop paying for their care
•
Replace all print and electronic copies of
beneficiary resources that include the QIO’s contact information
•
Update policies and procedures that contain a
reference to contact CFMC (contacts, address, telephone numbers, fax numbers)
Quality Innovation Network QIOs
Quality Innovation Network QIO (QIN-QIO) contract awards are expected to be announced in July. QIN-QIOs will be responsible for working with providers, practitioners, and the community on multiple data-driven quality initiatives to improve patient safety, reduce harm, and improve clinical care at the local and regional levels. The new QIN structure requires a multi-state, regional approach, but much of the work will still be performed at state level with each QIO offering tailored education, tools, and resources to health care providers in their states. The multi-state approach provides opportunities to share successes across states to facilitate rapid improvement.
