Kepro and the Case of 18 Prescriptions for One Patient

The newsletter reveals a startling revelation.

Last week Kepro, the BFCC-QIO (Beneficiary and Family Centered Care Quality Improvement Organization), hereafter referred to as “QIO”) for part of the country, released their monthly newsletter called Case Connections. In each issue, there is a little blurb from the medical director describing a recent initiative by the Centers for Medicare & Medicaid Services (CMS) or Kepro. To steal terminology from Reddit, this is usually “mildly interesting” at best. But if you stop reading there, you miss the good stuff.

This month they described Kepro’s online appeal tracking tool, even including a link to a YouTube video tutorial. I am a vendor and not in the hospital directly handling patient appeals so this might be old news but I did not know you could go online and see exactly where the patient’s appeal was in the process. I have heard of instances when the QIO is not so timely with their decision so this is a great way to track that and get written proof if you choose to escalate their poor performance to CMS.

What is a timely decision from the QIO on a patient appeal? Well, it is complicated. The Medicare Claims Processing Manual, chapter 30, section 200.5.6 states, “No later than one calendar day after it receives all requested information, the BFCC-QIO must make its determination on whether the discharge is appropriate based on medical necessity or other Medicare coverage policies.” So it is not a 24-hour period but the decision must be available by the end of the day on the day after they receive the information. How does CMS define the end of the day? Who knows…

Now what should you do if your QIO is not meeting the timeliness requirement? While patients can call 1-800-MEDICARE or the QIO if they have a complaint about hospitals, and Livanta even has a smartphone app so there is no “dialing” involved, there is no simple way to complain to CMS about the QIO. I would advise contacting your CMS Regional Office and asking them for help. It is important for CMS to understand that when patients are hospitalized and staying to await their appeal decision, the hospital incurs real costs to provide that care and any delays in receiving the QIO decisions costs money.

And as important as it is to report poor performance, do not forget to take the time to acknowledge excellent performance. If the QIO helps you out of a bind with a patient situation, thank them. If a specific employee goes out of their way to help you, contact their boss to ensure their work is recognized.

The other part of the newsletter that is always interesting to read is their “immediate advocacy success story.” This is where they get to brag about their good work.

This month they described the patient who was discharged from the hospital and the prescriptions were not available at the pharmacy as requested so the husband called Kepro for help. Kepro called the hospital and found out that the prescriptions were called to a different pharmacy because the requested pharmacy was closed for the weekend.

They called the patient’s husband with this information. As Kepro describes it, the husband expressed appreciation. But what struck me was the statement that “the pharmacy staff was called and stated they were working on filling the 18 prescriptions.”

Eighteen prescriptions? Seriously?  Can you imagine the drug interactions that happen inside that patient’s body? What is wrong with us that someone would think it appropriate to prescribe that many medications to one person? I would hope that if any of you encounter a patient on 18 medications you would talk to the doctor about a careful medication review and start deprescribing some medications.

This is also a good time to remind you that while we think about the QIO for patient discharge appeals, they are also available for patients to call with almost any issue as we saw in this case. If the patient does not like the food or their roommate, they can call the QIO. So if the QIO calls you, it may simply be a fact-finding call and not an official action. You may want to talk to your staff about how to handle such a call. How do you verify that they really are who they say they are? How much information can you release to them? At what point do you need to involve compliance or risk? 


Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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