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QIO Program

BFCC-QIO 12th SOW Annual Medical Services Review Report Contract Year 1 (June 8 - December 31, 2019) Region 1

BFCC-QIO 12TH SOW ANNUAL MEDICAL

SERVICES REVIEW REPORT

REGION 1

BFCC-QIO 12th SOW Annual Medical Services Review Report

KEPRO, Region 1, June 8 – December 31, 2019

Page | 2

TABLE OF CONTENTS Introduction: .................................................................................................................................................... 5

Annual Report Body: ........................................................................................................................................ 6

1) Total Number of Reviews ..................................................................................................................... 6

2) Top 10 Principal Medical Diagnoses .................................................................................................... 6

3) Provider Reviews Settings .................................................................................................................... 7

4) Quality of Care Concerns Confirmed and Quality Improvement Initiatives ........................................ 8

5) Discharge/Service Terminations ........................................................................................................... 9

6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital

Admissions Outcomes by Notification Type ...................................................................................... 10

7) Evidence Used in Decision-Making ................................................................................................... 11

8) Reviews by Geographic Area ............................................................................................................. 14

9) Outreach and Collaboration with Beneficiaries .................................................................................. 14

10) Immediate Advocacy Cases ................................................................................................................ 15

11) Example/Success Story ....................................................................................................................... 15

12) Beneficiary Helpline Statistics ............................................................................................................ 16

Conclusion: ...................................................................................................................................................... 16

APPENDIX ........................................................................................................................................................... 17

KEPRO BFCC-QIO REGION #1 – State of Connecticut ................................................................................ 17

1) Total Number of Reviews ................................................................................................................... 17

2) Top 10 Principal Medical Diagnoses .................................................................................................. 17

3) Beneficiary Demographics Possible Data Source ............................................................................... 18

4) Provider Reviews Settings .................................................................................................................. 18

5) Quality of Care Concerns Confirmed ................................................................................................. 19



7) Reviews by Geographic Area – Urban and Rural ............................................................................... 21


KEPRO BFCC-QIO REGION #1 – State of Maine ......................................................................................... 22






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KEPRO BFCC-QIO REGION #1 – State of Massachusetts ............................................................................ 27










KEPRO BFCC-QIO REGION #1 – State of New Hampshire ......................................................................... 32










KEPRO BFCC-QIO REGION #1 – State of Rhode Island .............................................................................. 37








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KEPRO BFCC-QIO REGION #1 – State of Vermont ..................................................................................... 42












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INTRODUCTION:

KEPRO is the Centers for Medicare & Medicaid Services

(CMS) designated Beneficiary and Family Centered Care

Quality Improvement Organization (BFCC-QIO) for Region

1, which covers the following states: Connecticut,

Massachusetts, Maine, New Hampshire, Rhode Island, and

Vermont. The Quality Improvement Organization (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 first year

of its BFCC-QIO contract. The first section of this report contains global data followed by an Appendix with

state-specific data.

The QIO Program is all about improving the quality, safety, and value of the care the Medicare beneficiary

receives through the Medicare program. 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, such as KEPRO, review complaints about the quality of medical care. They also provide an

appeal process for Medicare beneficiaries when a healthcare provider wants to discontinue services or discharge

the beneficiary from the hospital. KEPRO provides a service called Immediate Advocacy for beneficiaries who

want to quickly resolve a Medicare situation with a provider, which does not require a medical record review.

By providing these services, the rights of Medicare beneficiaries are protected while also protecting the

Medicare Trust Fund.

Region 1



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ANNUAL REPORT BODY:

1) TOTAL NUMBER OF REVIEWS

The data below reflects the total number of medical record reviews completed for Region 1.

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

healthcare 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.

• Potential Emergency Medical Treatment & Labor Act (EMTALA) violations – In 1986, Congress

enacted 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

Number of

Reviews

Percent of

Total Reviews

Quality of Care Review (Beneficiary Complaint) 45 1.24%

Quality of Care Review (All Other Selection Reasons) 4 0.11%

Notice of Non-coverage (Admission and Preadmission, HINN 1) 50 1.38%

Notice of Non-coverage (BIPA) 1,347 37.25%

Notice of Non-coverage (Grijalva) 1,532 42.37%

Notice of Non-coverage (Weichardt) 631 17.45%

Notice of Non-coverage (Request for QIO Concurrence/HINN 10) 3 0.08%

Emergency Medical Treatment & Labor Act (EMTALA) 5 Day 3 0.08%

EMTALA 60 Day 1 0.03%

Total 3,616 100.00%

2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES

Top 10 Medical Diagnoses

Number of

Beneficiaries

Percent of

Beneficiaries

1. A419 - SEPSIS, UNSPECIFIED ORGANISM 18,373 27.69%

2. I130 - HYP HRT & CHR KDNY DIS W HRT FAIL AND STG 1-

4/UNSP CHR KDNY 7,666 11.55%

3. I110 - HYPERTENSIVE HEART DISEASE WITH HEART FAILURE 6,610 9.96%

4. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 6,221 9.38%

5. N390 - URINARY TRACT INFECTION, SITE NOT SPECIFIED 5,178 7.80%



Page | 7


Number of

Beneficiaries

Percent of

Beneficiaries

6. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W

(ACUTE) EXACERBATION 5,072 7.64%

7. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL

INFARCTION 4,969 7.49%

8. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 4,932 7.43%

9. M1711 - UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT

KNEE 3,705 5.58%

10. J690 - PNEUMONITIS DUE TO INHALATION OF FOOD AND

VOMIT 3,623 5.46%

Total 66,349 100.00%

3) PROVIDER REVIEWS SETTINGS

Setting

Number of

Providers

Percent of

Providers

0: Acute Care Unit of an Inpatient Facility 109 14.53%

1: Distinct Psychiatric Facility 5 0.67%

2: Distinct Rehabilitation Facility 9 1.20%

3: Distinct Skilled Nursing Facility 539 71.87%

5: Clinic 0 0.00%

6: Distinct Dialysis Center Facility 0 0.00%

7: Dialysis Center Unit of Inpatient Facility 0 0.00%

8: Independent Based Rural Health Clinic (RHC) 0 0.00%

9: Provider Based Rural Health Clinic (RHC) 0 0.00%

C: Free Standing Ambulatory Surgery Center 0 0.00%

G: End Stage Renal Disease Unit 1 0.13%

H: Home Health Agency 36 4.80%

N: Critical Access Hospital 8 1.07%

O: Setting does not fit into any other existing setting code 0 0.00%

Q: Long-Term Care Facility 8 1.07%

R: Hospice 28 3.73%

S: Psychiatric Unit of an Inpatient Facility 3 0.40%

T: Rehabilitation Unit of an Inpatient Facility 1 0.13%

U: Swing Bed Hospital Designation for Short-Term, Long-Term Care, and

Rehabilitation Hospitals 0 0.00%

Y: Federally Qualified Health Centers 1 0.13%

Z: Swing Bed Designation for Critical Access Hospitals 2 0.27%

Other 0 0.00%

Total 750 100.00%



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4) QUALITY OF CARE CONCERNS CONFIRMED AND QUALITY IMPROVEMENT INITIATIVES

4.a. QUALITY OF CARE CONCERNS CONFIRMED

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.

Quality of Care (“C” Category) PRAF Category Codes

Number of

Concerns

Number of

Concerns

Confirmed

Percent

Confirmed

Concerns

C01: Apparently did not obtain pertinent history and/or findings from

examination 1 0 0.00%

C02: Apparently did not make appropriate diagnoses and/or

assessments 18 0 0.00%

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),

procedures (see C07 or C08) and consultations (see C13 and C14)]

32 2 6.25%

C04: Apparently did not carry out an established plan in a competent

and/or timely fashion 13 3 23.08%

C05: Apparently did not appropriately assess and/or act on changes in

clinical/other status results 2 0 0.00%

C06: Apparently did not appropriately assess and/or act on laboratory

tests or imaging study results 1 0 0.00%

C07: Apparently did not establish adequate clinical justification for a

procedure which carries patient risk and was performed 0 0 0.00%

C08: Apparently did not perform a procedure that was indicated (other

than lab and imaging, see C09) 4 0 0.00%

C09: Apparently did not obtain appropriate laboratory tests and/or

imaging studies 2 0 0.00%

C10: Apparently did not develop and initiate appropriate discharge,

follow-up, and/or rehabilitation plans 5 0 0.00%

C11: Apparently did not demonstrate that the patient was ready for

discharge 11 0 0.00%

C12: Apparently did not provide appropriate personnel and/or resources 1 0 0.00%

C13: Apparently did not order appropriate specialty consultation 3 1 33.33%

C14: Apparently specialty consultation process was not completed in a

timely manner 0 0 0.00%

C15: Apparently did not effectively coordinate across disciplines 0 0 0.00%

C16: Apparently did not ensure a safe environment (medication errors,

falls, pressure ulcers, transfusion reactions, nosocomial infection) 6 1 16.67%



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Number of

Concerns

Number of

Concerns

Confirmed

Percent

Confirmed

Concerns

C17: Apparently did not order/follow evidence-based practices 1 0 0.00%

C18: Apparently did not provide medical record documentation that

impacts patient care 0 0 0.00%

C40: Apparently did not follow up on patient’s non-compliance 0 0 0.00%

C99: Other quality concern not elsewhere classified 5 0 0.00%

Total 105 7 6.67%

4.b. QUALITY IMPROVEMENT INITIATIVES (QII)

QII data is not included in the Contract Year 1 (CY1) BFCC-QIO 12th SOW Annual Medical Services Review

Report. QII referrals were paused during the date range in this report due to the procurement process and

transition from 11th to 12th Statement of Work.

5) DISCHARGE/SERVICE TERMINATIONS

The data below reflects the discharge location of beneficiaries linked to discharge/service termination reviews

for Request for BFCC-QIO Concurrence and Weichardt Reviews completed in Region 1. Please note that the

discharge location data for the completed appeals reported may be incomplete because of the inability to link

them from the claims data.

Note: Data contained in this table represent discharge/service termination reviews from June 8, 2019, to

December 31, 2019. 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

Number of

Beneficiaries

Percent of

Beneficiaries

01: Discharged to home or self care (routine discharge) 3 27.27%

02: Discharged/transferred to another short-term general hospital for inpatient

care 0 0.00%

03: Discharged/transferred to skilled nursing facility (SNF) 6 54.55%

04: Discharged/transferred to intermediate care facility (ICF) 0 0.00%

05: Discharged/transferred to another type of institution (including distinct parts) 0 0.00%

06: Discharged/transferred to home under care of organized home health service

organization 1 9.09%

07: Left against medical advice or discontinued care 0 0.00%

09: Admitted as an inpatient to this hospital 0 0.00%

20: Expired (or did not recover – Christian Science patient) 0 0.00%

21: Discharged/transferred to court/law enforcement 0 0.00%

30: Still a patient 0 0.00%

40: Expired at home (Hospice claims only) 0 0.00%



Page | 10

Discharge Status

Number of

Beneficiaries

Percent of

Beneficiaries

41: Expired in a medical facility (e.g., hospital, SNF, ICF, or free standing

Hospice) 0 0.00%

42: Expired – place unknown (Hospice claims only) 0 0.00%

43: Discharged/transferred to a federal hospital 0 0.00%

50: Hospice - home 1 9.09%

51: Hospice - medical facility 0 0.00%

61: Discharged/transferred within this institution to a hospital-based, Medicare-

approved swing bed 0 0.00%

62: Discharged/transferred to an inpatient rehabilitation facility including

distinct part units of a hospital 0 0.00%

63: Discharged/transferred to a long-term care hospital 0 0.00%

64: Discharged/transferred to a nursing facility certified under Medicaid but not

under Medicare 0 0.00%

65: Discharged/transferred to a psychiatric hospital or psychiatric distinct part

unit of a hospital 0 0.00%

66: Discharged/transferred to a critical access hospital 0 0.00%

70: Discharged/transferred to another type of health care institution not defined

elsewhere in code list 0 0.00%

Other 0 0.00%

Total 11 100.00%

6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF

HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE

The data below 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 hospital discharge or discontinuation of skilled

services decision.

Appeal Review by Notification Type

Number

of

Reviews

Physician

Reviewer

Disagreed with

Discharge (%)

Physician

Reviewer

Agreed with

Discharge (%)

Notice of Non-coverage FFS Preadmission/Admission -

(Admission and Preadmission/HINN 1) 46 32.61% 67.39%

Notice of Non-coverage Request for BFCC-QIO Concurrence -

(Request for BFCC-QIO Concurrence/HINN 10) 3 33.33% 66.67%

MA Appeal Review (CORF, HHA, SNF) – (Grijalva) 1,292 34.98% 65.02%

FFS Expedited Appeal (CORF, HHA, Hospice, SNF) – (BIPA) 1,251 22.54% 77.46%

Notice of Non-coverage Hospital Discharge Notice - Attending

Physician Concurs - (FFS Weichardt) 469 6.40% 93.60%

MA Notice of Non-coverage Hospital Discharge Notice -

Attending Physician Concurs - (MA Weichardt) 120 8.33% 91.67%

Total 3,181 24.83% 75.17%



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7) EVIDENCE USED IN DECISION-MAKING

The table that follows describes the most common types of evidence or standards of care used to support

KEPRO Review Analysts’ assessments, which 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 of the most highly utilized types of

evidence/standards of care to support KEPRO Review Analysts’ assessments, which 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.

Review Type

Diagnostic

Categories

Evidence/

Standards of

Care Used

Rationale for Evidence/Standard of

Care Selected

Quality of Care Pneumonia CMS’ Pneumonia

indicators (PN 2-7)

UpToDate®

CMS’ guidelines for the management of

patients with Community Acquired

Pneumonia (CAP) address basic aspects

of preventive care and treatment. 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 healthcare

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.

Heart Failure American College of

Cardiology (ACC);

CMS’ Heart Failure

indicators (HF 1-3)

UpToDate®

ACC’s guidelines for the management of

patients with heart failure address

aspects of care that when followed are

associated with improved patient

outcomes.










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outcomes.

Pressure Ulcers AHRQ website;

Wound, Ostomy &

Continence Nursing

website

(www.WOCN.org)

CMS’ Hospital

Acquired Conditions

& Patient Safety

Indicators (PSI-03 &

PSI-90 Composite

Measure)

UpToDate®

The Agency for Healthcare 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.









outcomes.

Acute Myocardial

Infarction

American College of

Cardiology (ACC)

Acute Myocardial

Infarction

Guidelines; CMS’

Acute Myocardial

Infarction indicators

(AMI 2-10)

UpToDate®

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.









outcomes.

Urinary Tract

Infection

HAI-CAUTI (f/k/a

HAC-7)

UpToDate®

CMS’ PSIs are measurements of quality

of patient care during hospitalization and

were developed by AHRQ after years of







Page | 13









outcomes.

Sepsis Institute for

Healthcare

Improvement (IHI)

UpToDate®

IHI developed sepsis indicators and

guidelines for the identification and

treatment of sepsis. Adherence to such

guidelines has improved patient

outcomes.









outcomes.

Adverse Drug

Events

CMS’ Hospital

Acquired Conditions

& Patient Safety


PSI-90 Composite

Measure)








Falls CMS’ Hospital

Acquired Conditions

& Patient Safety


PSI-90 Composite

Measure)








Patient Trauma CMS’ Hospital

Acquired Conditions

& Patient Safety


PSI-90 Composite

Measure)








Surgical

Complications

Surgical

complications

KEPRO’s Generic Quality Screening

Tool



Page | 14

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 BFCC-QIO review.

Table 8A: Appeal Reviews by Geographic Area – Urban and Rural

Geographic Area Number of Providers Percent of Providers in Service Area

Urban 662 90.56%

Rural 65 8.89%

Unknown 4 0.55%

Total 731 100.00%

Table 8B: Quality of Care Reviews by Geographic Area – Urban and Rural

Geographic Area Number of Providers Percent of Providers in Service Area

Urban 26 92.86%

Rural 2 7.14%

Unknown 0 0.00%

Total 28 100.00%

9) OUTREACH AND COLLABORATION WITH BENEFICIARIES

KEPRO developed a collaborative partnership with the Massachusetts Senior Medicare Patrol (SMP) program,

which empowers Medicare beneficiaries and their families to become engaged healthcare consumers. The MA

SMP program conducted approximately 50 outreach and education events, reaching more than 8,000 Medicare

beneficiaries. Information about KEPRO’s services was included in the MA SMP program’s “Gaining Access”

flyer, a comprehensive resource guide for the 1.3 million Medicare beneficiaries in Massachusetts. A

presentation was also done at the MA SMP Case Management meeting, where information about KEPRO was

shared with case managers throughout the state.

Appeals National Coverage

Determination

Guidelines; JIMMO

settlement language

and guidelines,

InterQual®, and

CMS’ Two Midnight

Rule Benchmark

criteria

Determination Guidelines; JIMMO

settlement language and guidelines,

InterQual®, and CMS’ Two Midnight

Rule Benchmark criteria

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

KEPRO also developed a valuable partnership with the New Hampshire Hospital Association. At the start of the

12th SOW, KEPRO presented to the New Hampshire Hospital Association and shared information about the

BFCC-QIO’s services and addressed questions to help smooth the contract transition and establish a good

rapport with providers across the state. KEPRO has maintained a relationship with this stakeholder, sharing

important updates and information about services as well as providing the hospital association with educational

materials. KEPRO’s information and materials are shared with the 30 registered hospitals that are a part of the

New Hampshire Hospital Association serving the state’s 295,000 Medicare beneficiaries.

10) IMMEDIATE ADVOCACY CASES

The data below 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 (IA) is an informal process used by KEPRO to quickly resolve

an oral complaint about medical care or services. It involves KEPRO contacting a practitioner, healthcare

provider, or facility on behalf of the beneficiary. Some of the benefits of the IA process include resolving

complaints that are not right for a medical record review, improved satisfaction for the Medicare beneficiary

and the provider, and a quicker time to resolve the concern.

Number of

Beneficiary Complaints

Number of Immediate

Advocacy Cases

Percent of Total Beneficiary

Complaints Resolved by Immediate

Advocacy

116 84 72.41%

11) EXAMPLE/SUCCESS STORY

A Medicare beneficiary contacted KEPRO with concerns about his follow-up care after surgery. He was in pain

after surgery on his right foot, and the doctors that performed the surgery would not see him for follow-up care.

He was on an IV due to an infection in his foot and requested an intervention by KEPRO.

KEPRO’s Clinical Care Coordinator (CCC) contacted the case manager at the hospital where the surgery was

performed, to advocate for the beneficiary’s proper treatment and follow-up care. The case manager stated that

the wound doctor did not want to do follow-up with the beneficiary, due to his noncompliance. She stated that

she would contact another wound care physician for the follow-up care and the foot pain issue and that she was

also handling the IV situation. The CCC called the beneficiary to let him know that the hospital case manager

would be addressing his concerns. He stated that he was satisfied with the intervention.



Page | 16

12) BENEFICIARY HELPLINE STATISTICS

Beneficiary Helpline Report Total Per Category

Total Number of Calls Received 33,982

Total Number of Calls Answered 24,758

Total Number of Abandoned Calls 4,510

Average Length of Call Wait Times* 00:04:51 (291 Secs)

Number of Calls Transferred by 1-800-Medicare 287

* In the time frame from June 9 – December 31, 2019, KEPRO’s Average Length of Call Wait Times was

directly impacted by the transition from its proprietary appeal system to the CMS designated Case Review

System – QMARS. KEPRO followed CMS’ instructions and in June/July 2019 experienced a very difficult time

working within the QMARS application and subsequently reverted back to our internal appeals system mid-

July. The difficulties experienced included tripling the amount of time required to initiate an appeal – increasing

from approximately 15 minutes in KEPRO’s internal system to as much as 45 minutes in CMS’ QMARS

application. This increase in processing time increased the overall number of inbound calls, increased wait

times, increased the number of voice mail messages that were left and required processing, and resulted in

decreased satisfaction with KEPRO’s handling of calls.

In mid-July, KEPRO returned to using its proprietary appeal system, and by mid-August, our call center volume

returned to industry standard benchmarks. Call wait times were less than two minutes, abandonment rate was

less than 5%, and the percentage of calls answered with 30 seconds was 85%.

CONCLUSION:

KEPRO’s outcomes and findings for year one 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.



Page | 17

APPENDIX

KEPRO BFCC-QIO REGION #1 – STATE OF CONNECTICUT


Review Type

Number of

Reviews

Percent of

Total Reviews



Notice of Non-coverage (Admission and Preadmission/HINN 1) 2 0.14%

Notice of Non-coverage (BIPA) 515 35.52%

Notice of Non-coverage (Grijalva) 764 52.69%





Total 1,450 100.00%



Number of

Beneficiaries

Percent of

Beneficiaries


2. I130 - HYP HRT & CHR KDNY DIS W HRT FAIL AND STG

1-4/UNSP CHR KDNY 1,552 11.11%


4. I110 - HYPERTENSIVE HEART DISEASE WITH HEART

FAILURE 1,358 9.72%


6. M1711 - UNILATERAL PRIMARY OSTEOARTHRITIS,

RIGHT KNEE 831 5.95%

7. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 830 5.94%


INFARCTION 781 5.59%

9. M1712 - UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT

KNEE 744 5.32%


(ACUTE) EXACERBATION 743 5.32%

Total 13,975 100.00%



Page | 18

3) BENEFICIARY DEMOGRAPHICS POSSIBLE DATA SOURCE

Demographics Number of Beneficiaries Percent of Beneficiaries

Sex/Gender

Female 880 61.37%

Male 554 38.63%

Unknown 0 0.00%

Total 1,434 100.00%

Race

Asian 9 0.63%

Black 124 8.65%

Hispanic 10 0.70%

North American Native 0 0.00%

Other 10 0.70%

Unknown 26 1.81%

White 1,255 87.52%

Total 1,434 100.00%

Age

Under 65 103 7.18%

65-70 150 10.46%

71-80 418 29.15%

81-90 543 37.87%

91+ 220 15.34%

Total 1,434 100.00%


Setting

Number of

Providers

Percent of

Providers





5: Clinic 0 0.00%











R: Hospice 7 3.37%



Page | 19

Setting

Number of

Providers

Percent of

Providers







Other 0 0.00%

Total 208 100.00%

5) QUALITY OF CARE CONCERNS CONFIRMED


Number

of

Concerns

Number of

Concerns

Confirmed

Percent

Confirmed

Concerns



C02: Apparently did not make appropriate diagnoses and/or assessments 4 0 0.00%

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)]

7 1 14.29%
















discharge 3 0 0.00%








Page | 20


Number

of

Concerns

Number of

Concerns

Confirmed

Percent

Confirmed

Concerns








Total 32 4 12.50%

*QII data is not included in the Contract Year 1 (CY1) BFCC-QIO 12th SOW Annual Medical Services Review

Report. QII referrals were paused during the date range in this report due to procurement process and




Appeal Reviews by Notification Type

Number of

Reviews

Percent

of Total

Notice of Non-coverage FFS Preadmission/Admission Notice - (Admission and

Preadmission/HINN 1) 2 0.16%

Notice of Non-coverage Request for BFCC-QIO Concurrence - (Request for BFCC-

QIO Concurrence/HINN 10) 0 0.00%

MA Appeal Review (CORF, HHA, SNF) - (Grijalva) 651 51.02%

FFS Expedited Appeal (CORF, HHA, Hospice, SNF) - (BIPA) 480 37.62%

Notice of Non-coverage Hospital Discharge Notice - Attending Physician Concurs -

(FFS Weichardt) 107 8.39%

MA Notice of Non-coverage Hospital Discharge Notice - Attending Physician Concurs

- (MA Weichardt) 36 2.82%

Total 1,276 100.00%

Quality of Care Concerns Referred for Quality Improvement Initiatives (QIIs)

Number of Concerns Referred for QII Percent of Quality of Care Concerns

Referred for QII

N/A* N/A*



Page | 21

7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL


Geographic Area Number of Providers

Percent of

Providers in State

Percent of Providers in

Service Area

Urban 194 94.63% 90.56%

Rural 9 4.39% 8.89%

Unknown 2 0.98% 0.55%

Total 205 100.00% 100.00%



Percent of

Providers in State


Service Area

Urban 8 100.00% 92.86%

Rural 0 0.00% 7.14%

Unknown 0 0.00% 0.00%

Total 8 100.00% 100.00%


Number of Beneficiary

Complaints

Number of Immediate

Advocacy Cases

Percent of Total Beneficiary Complaints

Resolved by Immediate Advocacy

27 21 77.78%



Page | 22

KEPRO BFCC-QIO REGION #1 – STATE OF MAINE


Review Type

Number of

Reviews

Percent of

Total Reviews










Total 236 100.00%



Number of

Beneficiaries

Percent of

Beneficiaries





4/UNSP CHR KDNY 650 11.07%

4. I110 - HYPERTENSIVE HEART DISEASE WITH HEART FAILURE 495 8.43%



6. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 437 7.44%


8. N390 - URINARY TRACT INFECTION, SITE NOT SPECIFIED 354 6.03%


VOMIT 326 5.55%

10. M1612 - UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT HIP 281 4.79%

Total 5,872 100.00%



Page | 23



Sex/Gender

Female 145 57.31%

Male 108 42.69%

Unknown 0 0.00%

Total 253 100.00%

Race

Asian 0 0.00%

Black 5 1.98%

Hispanic 0 0.00%


Other 0 0.00%

Unknown 3 1.19%

White 245 96.84%

Total 253 100.00%

Age

Under 65 37 14.62%

65-70 39 15.42%

71-80 66 26.09%

81-90 86 33.99%

91+ 25 9.88%

Total 253 100.00%


Setting

Number of

Providers

Percent of

Providers





5: Clinic 0 0.00%













Page | 24

Setting

Number of

Providers

Percent of

Providers

R: Hospice 0 0.00%







Other 0 0.00%

Total 65 100.00%



Number

of

Concerns

Number of

Concerns

Confirmed

Percent

Confirmed

Concerns






episode of care [excludes laboratory and/or imaging (see C06 or C09)

and procedures (see C07 or C08) and consultations (see C13 and C14)]

1 0 0.00%
















discharge 4 0 0.00%








Page | 25


Number

of

Concerns

Number of

Concerns

Confirmed

Percent

Confirmed

Concerns








Total 6 0 0.00%







Number of

Reviews

Percent

of Total











Total 208 100.00%



Referred for QII

N/A* N/A*



Page | 26




Percent of

Providers in State


Service Area

Urban 39 60.94% 90.56%

Rural 24 37.50% 8.89%

Unknown 1 1.56% 0.55%

Total 64 100.00% 100.00%



Percent of

Providers in State


Service Area

Urban 1 50.00% 92.86%

Rural 1 50.00% 7.14%

Unknown 0 0.00% 0.00%

Total 2 100.00% 100.00%



Complaints

Number of Immediate

Advocacy Cases



6 4 66.67%



Page | 27

KEPRO BFCC-QIO REGION #1 – STATE OF MASSACHUSETTS


Review Type

Number of

Reviews

Percent of

Total Reviews










Total 1,194 100.00%



Number of

Beneficiaries

Percent of

Beneficiaries



4/UNSP CHR KDNY 3,988 12.05%

3. I110 - HYPERTENSIVE HEART DISEASE WITH HEART FAILURE 3,349 10.12%



(ACUTE) EXACERBATION 2,766 8.36%


7. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 2,507 7.58%


INFARCTION 2,235 6.76%


KNEE 1,961 5.93%


VOMIT 1,932 5.84%

Total 33,086 100.00%



Page | 28



Sex/Gender

Female 695 61.56%

Male 434 38.44%

Unknown 0 0.00%

Total 1,129 100.00%

Race

Asian 6 0.53%

Black 43 3.81%

Hispanic 9 0.80%


Other 14 1.24%

Unknown 13 1.15%

White 1,044 92.47%

Total 1,129 100.00%

Age

Under 65 104 9.21%

65-70 106 9.39%

71-80 312 27.64%

81-90 399 35.34%

91+ 208 18.42%

Total 1,129 100.00%


Setting

Number of

Providers

Percent of

Providers





5: Clinic 0 0.00%













Page | 29

Setting

Number of

Providers

Percent of

Providers

R: Hospice 14 4.53%







Other 0 0.00%

Total 309 100.00%



Number

of

Concerns

Number of

Concerns

Confirmed

Percent

Confirmed

Concerns








18 0 0.00%
















discharge 1 0 0.00%








Page | 30


Number

of

Concerns

Number of

Concerns

Confirmed

Percent

Confirmed

Concerns








Total 49 2 4.08%







Number of

Reviews

Percent

of Total











Total 1,053 100.00%



Referred for QII

N/A* N/A*



Page | 31




Percent of

Providers in State


Service Area

Urban 291 98.31% 90.56%

Rural 5 1.69% 8.89%

Unknown 0 0.00% 0.55%

Total 296 100.00% 100.00%



Percent of

Providers in State


Service Area

Urban 13 100.00% 92.86%

Rural 0 0.00% 7.14%

Unknown 0 0.00% 0.00%

Total 13 100.00% 100.00%



Complaints

Number of Immediate

Advocacy Cases



59 43 72.88%



Page | 32

KEPRO BFCC-QIO REGION #1 – STATE OF NEW HAMPSHIRE


Review Type

Number of

Reviews

Percent of

Total Reviews










Total 191 100.00%



Number of

Beneficiaries

Percent of

Beneficiaries












9. M1611 - UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT HIP 422 5.82%

10. I480 - PAROXYSMAL ATRIAL FIBRILLATION 379 5.23%

Total 7,251 100.00%



Page | 33



Sex/Gender

Female 128 58.45%

Male 91 41.55%

Unknown 0 0.00%

Total 219 100.00%

Race

Asian 0 0.00%

Black 0 0.00%

Hispanic 1 0.46%


Other 1 0.46%

Unknown 5 2.28%

White 212 96.80%

Total 219 100.00%

Age

Under 65 38 17.35%

65-70 35 15.98%

71-80 49 22.37%

81-90 74 33.79%

91+ 23 10.50%

Total 219 100.00%


Setting

Number of

Providers

Percent of

Providers





5: Clinic 0 0.00%












Page | 34

Setting

Number of

Providers

Percent of

Providers


R: Hospice 4 6.25%







Other 0 0.00%

Total 64 100.00%



Number

of

Concerns

Number of

Concerns

Confirmed

Percent

Confirmed

Concerns








3 1 33.33%
















discharge 0 0 0.00%







Page | 35


Number

of

Concerns

Number of

Concerns

Confirmed

Percent

Confirmed

Concerns









Total 10 1 10.00%







Number of

Reviews

Percent

of Total











Total 170 100.00%



Referred for QII

N/A* N/A*



Page | 36




Percent of

Providers in State


Service Area

Urban 49 77.78% 90.56%

Rural 13 20.63% 8.89%

Unknown 1 1.59% 0.55%

Total 63 100.00% 100.00%



Percent of

Providers in State


Service Area

Urban 3 75.00% 92.86%

Rural 1 25.00% 7.14%

Unknown 0 0.00% 0.00%

Total 4 100.00% 100.00%



Complaints

Number of Immediate

Advocacy Cases



11 5 45.45%



Page | 37

KEPRO BFCC-QIO REGION #1 – STATE OF RHODE ISLAND


Review Type

Number of

Reviews

Percent of

Total Reviews










Total 459 100.00%



Number of

Beneficiaries

Percent of

Beneficiaries

1. A419 - SEPSIS, UNSPECIFIED ORGANISM 833 24.52%












VOMIT 186 5.48%

10. M1611 - UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT HIP 172 5.06%

Total 3,397 100.00%



Page | 38



Sex/Gender

Female 268 63.96%

Male 151 36.04%

Unknown 0 0.00%

Total 419 100.00%

Race

Asian 1 0.24%

Black 11 2.63%

Hispanic 5 1.19%


Other 4 0.95%

Unknown 3 0.72%

White 395 94.27%

Total 419 100.00%

Age

Under 65 41 9.79%

65-70 44 10.50%

71-80 105 25.06%

81-90 166 39.62%

91+ 63 15.04%

Total 419 100.00%


Setting

Number of

Providers

Percent of

Providers





5: Clinic 0 0.00%













Page | 39

Setting

Number of

Providers

Percent of

Providers

R: Hospice 2 2.47%







Other 0 0.00%

Total 81 100.00%



Number

of

Concerns

Number of

Concerns

Confirmed

Percent

Confirmed

Concerns








3 0 0.00%
















discharge 3 0 0.00%








Page | 40


Number

of

Concerns

Number of

Concerns

Confirmed

Percent

Confirmed

Concerns








Total 8 0 0.00%







Number of

Reviews

Percent

of Total











Total 399 100.00%



Referred for QII

N/A* N/A*



Page | 41




Percent of

Providers in State


Service Area

Urban 81 100.00% 90.56%

Rural 0 0.00% 8.89%

Unknown 0 0.00% 0.55%

Total 81 100.00% 100.00%



Percent of

Providers in State


Service Area

Urban 1 100.00% 92.86%

Rural 0 0.00% 7.14%

Unknown 0 0.00% 0.00%

Total 1 100.00% 100.00%



Complaints

Number of Immediate

Advocacy Cases



10 8 80.00%



Page | 42

KEPRO BFCC-QIO REGION #1 – STATE OF VERMONT


Review Type

Number of

Reviews

Percent of

Total Reviews










Total 86 100.00%



Number of

Beneficiaries

Percent of

Beneficiaries

1. A419 - SEPSIS, UNSPECIFIED ORGANISM 688 21.06%











9. M1712 - UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT KNEE 199 6.09%


KNEE 187 5.72%

Total 3,267 100.00%



Page | 43



Sex/Gender

Female 40 57.14%

Male 30 42.86%

Unknown 0 0.00%

Total 70 100.00%

Race

Asian 0 0.00%

Black 1 1.43%

Hispanic 0 0.00%


Other 1 1.43%

Unknown 0 0.00%

White 68 97.14%

Total 70 100.00%

Age

Under 65 7 10.00%

65-70 6 8.57%

71-80 16 22.86%

81-90 29 41.43%

91+ 12 17.14%

Total 70 100.00%


Setting

Number of

Providers

Percent of

Providers





5: Clinic 0 0.00%













Page | 44

Setting

Number of

Providers

Percent of

Providers

R: Hospice 1 4.35%







Other 0 0.00%

Total 23 100.00%



Number

of

Concerns

Number of

Concerns

Confirmed

Percent

Confirmed

Concerns








0 0 0.00%
















discharge 0 0 0.00%








Page | 45


Number

of

Concerns

Number of

Concerns

Confirmed

Percent

Confirmed

Concerns








Total 0 0 0.00%







Number of

Reviews

Percent

of Total











Total 75 100.00%



Referred for QII

N/A* N/A*



Page | 46




Percent of

Providers in State


Service Area

Urban 8 36.36% 90.56%

Rural 14 63.64% 8.89%

Unknown 0 0.00% 0.55%

Total 22 100.00% 100.00%



Percent of

Providers in State


Service Area

Urban 0 0.00% 0.00%

Rural 0 0.00% 0.00%

Unknown 0 0.00% 0.00%

Total 0 0.00% 0.00%



Complaints

Number of Immediate

Advocacy Cases



3 3 100.00%

Publication No. R1-92-5/2020. This material was prepared by KEPRO, a Medicare Quality Improvement Organization 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.

annual medical services review report - region 1 · bfcc-qio 12th sow annual medical services...

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