When the QIO Answer to the Webinar Question Does Not Answer the Question

When the QIO Answer to the Webinar Question Does not Answer the Question

I promise I do not do this intentionally. Each week, I look for topics of interest and report on them. And you know they are as varied as can be.

But this is now the third week in a row that I must be critical of a Medicare contractor. If you haven’t been reading regularly, first, this month was Palmetto, for being unable to interpret the word “and” in a National Coverage Determination (NCD) and inappropriately denying a pacemaker placement. Then, last week it was one of the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) for not knowing that a patient without Medicare Part A does not have expedited discharge appeal rights.

Now, this week, it is Kepro. First, you should know that they are changing their name. They report that they will soon be known as Acentra Health. Of course, that will mean every hospital they serve as QIO will need to redo all their forms with the new name. Just what you all need – more menial work that adds no value.

But what did they do to deserve my attention this week?

Well, they released a newsletter with answers to questions asked during a webinar on appeals. Well, let me rephrase that: they released several questions with answers, but that included several answers that in no way addressed the question that was actually asked.

What do I mean?

Question No. 1 was: If the representative states that he/she does not want a copy of the Important Message from Medicare (IMM) or the Detailed Notice of Discharge (DND), can we document that and not provide a copy? That’s a pretty reasonable question, I’d say. Many patients never read the stack of papers they get, and should rightly have the option to refuse to receive their copies. They’ll happily sign the form, but don’t want to contribute to the death of another tree.

So, what did Kepro answer? “The expedited determination process is available to beneficiaries in Original Medicare who are being discharged from a Medicare-covered inpatient hospital stay. All beneficiaries receiving covered inpatient hospital care must receive an IMM.” Yes, Kepro, we all know every patient must receive the IMM and sign it or refuse to sign, but can they decline the copy? We don’t know, because Kepro did not answer the question.

Question No. 2 was: Is there any guidance on whether the discharge order needs to be in place at a hospital before the appeal is made? That is an even better question. Many of us have heard from doctors that even though the patient is stable enough to be discharged and there is a safe discharge plan unless they know the patient is going to leave, they are unwilling to write the actual discharge order (even though they document the patient’s stability to discharge).

So, what did Kepro answer here? Let me recite their whole response: “Hospitals must deliver the follow-up copy of the IMM within two days of discharge. It may be given as late as four hours prior to discharge. However, if delivery of the first IMM is within two calendar days of the date of discharge, no follow-up notice is required. For example, if a beneficiary is admitted on Monday, the IMM is delivered on Wednesday, and the beneficiary is discharged on Friday, no follow-up notice is required.”

Seriously? That’s their response, in writing, distributed to everyone on their mailing list? Written weeks after the webinar, meaning they had all the time in the world to research the answer or even pick up the phone and call the Centers for Medicare & Medicaid Services (CMS) for an answer. Their answer did not include one single word about the need for the discharge order.

And the amazing part of that lack of a response is that Chapter 30 of the Medicare Claims Processing Manual, section 200.3.4.1, clearly states the order is not necessary to deliver the follow-up copy of the IMM. And then section 200.4.1.1 states “A beneficiary who receives an IMM and disagrees with the discharge may request an expedited determination.” That is right: CMS manuals make it clear that a discharge order in the record is not necessary for a patient to file an appeal. The delivery of the IMM is enough for the patient to call.

Although I did not discuss this on Monitor Mondays, I also have to take issue with some of the data they presented in their region report. They begin with reporting for Region 4, for example, that they did a total of 44,166 reviews of all types, the majority (76.92 percent) being appeals of the termination of skilled nursing facility (SNF) care or home health services (often called Grijalva appeals). But in the next table, they report the top 10 principal medical diagnoses, with sepsis, A419, with 100,846 beneficiaries, representing 29.43 percent of the total of the 342,693 beneficiaries.

Wait, did 342,693 beneficiaries contact Kepro in Region 4? That makes no sense. Now, if they are stating that there were 342,693 beneficiaries who reviewed Medicare services in Region 4 in 2023, and almost 30 percent had a principal diagnosis of sepsis, that information would be crucial to interpreting their data and providing some interesting information about the prevalence of specific diagnoses.

But does that number encompass only patients admitted to acute-care hospitals, critical access hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, and long-term acute-care hospitals, or does it include SNF admissions and home health episodes of care? Or others? We just don’t know, because Kepro does not tell us the context for that number anywhere in the document. More details on the origin of that data would be so helpful.       

Now, I must point out that this newsletter did contain some useful information. Kepro posted links to their annual statistics on their activities, and most useful to this audience is that when patients do appeal their discharge, Kepro agreed with the hospital over 90 percent of the time in all of their regions, for both Medicare and Medicare Advantage patients. That is quite reassuring, although I am sure most of us would love to see the details of the few where Kepro sided with the patient.

Finally, it is interesting to note that in their statistical reports, Kepro describes that they use UpToDate® and InterQual®, among other resources, when making determinations. I do wonder if either of those meet CMS’s standard for evidence-based criteria, as delineated in 42 § CFR 422.101, although Kepro does describe UpToDate® in quite glowing terms, stating six times in the Region 4 report that “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.” I don’t think UpToDate® could have said it better themselves.

As I have discussed in other articles, Medicare regulations are complicated and often contradictory. Thousands of pages are released each year, some creating new rules and others modifying prevailing rules. CMS knows that the tens of thousands of provider staffers that are tasked with ensuring compliance with those rules cannot know it all, so they enlist contractors who are tasked with being the expert resources on which providers around the country can rely for answers.

And I certainly do not expect these contractors to be able to answer every question posed on every webinar they provide, but it should not be too much to ask that when they cannot answer a question live, the written answer they do provide later actually answers the question.

Please do better, Acentra Health.

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Ronald Hirsch, MD, FACP, ACPA-C, 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, and the National Association of Healthcare Revenue Integrity, 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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