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)
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.
More information on the QIO Program can be found at QIOProgram.org or by contacting 1-800-MEDICARE.
