As a contractor for Medicare, Kepro serves as the Beneficiary and Family Centered Care Quality Improvement Organization, also referred to as a BFCC-QIO. While Kepro provides BFCC-QIO services in 29 states, the general information is relevant to everyone who has Medicare (including Medicare Advantage) and everyone who works with people who have Medicare. In Episode 1, host Scott Fortin, Senior Director, Communications and Outreach at Kepro, is joined by BFCC Program Director, Cheryl Cook, RN. The conversation gives listeners details about the free services Kepro offers for people who have Medicare to help them exercise their right to high quality health care. For more information about Kepro BFCC-QIO, please visit www.keproqio.com.
00:25: Overview, introduction
09:00: Quality of care complaints
15:30: Immediate Advocacy services
22:30: Information about Kepro BFCC-QIO, website
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Welcome to Aging Health Matters, a podcast from Kepro, a Beneficiary and Family Centered Care Quality Improvement Organization. We plan to cover healthcare topics for the Medicare population. The information in today’s show may help you or someone you know in their healthcare journey. Thanks for joining us; now let’s get started.
Good day everybody, and welcome to Kepro’s inaugural podcast. My name is Scott Fortin. I'm the Director of Communications and Outreach for the Kepro BFCC-QIO program, that is the Beneficiary and Family Centered Care Quality Improvement Organization program, and we do work on behalf of Medicare.
Our purpose today is to tell you a little bit more about that and give you a general overview of Kepro and its services that we offer out to the healthcare environment. With me today, I have our program director, Cheryl Cook. Hi Cheryl. How are you doing?
Hey Scott, I'm doing fine. Thank you.
Great. Well, thanks for joining me today. I plan to go through a little bit of an introduction about who Kepro is, what the BFCC-QIO does. And then Cheryl and I are going to talk through some areas in detail of how we serve Medicare beneficiaries or Medicare consumers. We do use those two terms interchangeably just to let you know.
So to begin, a Beneficiary and Family Centered Care organization, or BFCC-QIO, is an entity that every person who has Medicare and has rights under the Medicare program has eligibility for. So if someone has an issue with their care and they need a review of that care or an appeal of a potential discharge from a healthcare provider environment, that's where Kepro comes in.
So to back up and give you a little bit more of the environment in total, there are two contractors that take care of this type of work throughout the United States and their territories.
Kepro handles 29 of those states, ranging from the East Coast through the middle of the United States and all the way over far West into Alaska. Some of these services that we provide are appeals. And so Cheryl, if you would, I'd kind of like to talk about some things that we do, such as the types of appeals that we offer, a couple of them, and then some descriptions of people, how they go through that process of reaching out to Kepro through our phone lines and what happens when that occurs?
OK, Scott. Well, I can certainly provide some general information about appeals as a whole. All Medicare recipients, beneficiaries, even those that are part of a Medicare health plan, do have the right to ask for a review when there is a pending hospital discharge or perhaps they're in a skilled nursing facility, and that facility is going to discontinue certain skilled services. There are several types of appeals. Typically, they're going to either involve a hospital setting, or they're going to involve some type of post hospital settings such as skilled nursing facility, home health agency, perhaps even hospice, and then lastly, could involve an entity that is commonly referred to as a CORF, that's CORF, and that stands for a comprehensive outpatient rehabilitation facility.
Basically, if a Medicare beneficiary feels they're not ready for that care to be stopped, then they can call the QIO, the BFCC-QIO, and ask for an appeal of their care that has been rendered and whether or not stopping that care would put them in any harm. We really are looking at is the patient ready to go to the next level of care, which would be a lower level, so if the patient’s in a hospital, are they ready to go home, or do they need to go to a skilled nursing facility for some continued therapies?
In those post-acute settings I've described before, we're really looking at to see whether or not stopping the appeal would cause any potential harm in the patient.
If they're in a skilled nursing facility and skilled care is going to be stopped, we're really looking to see whether or not that patient is ready for that care to be stopped. Have they been taught how to take care of their condition? Has their family been taught how to take care of that condition? Are they going to a safe location in their discharge out of that facility? So that's really what we're looking at. All appeals start the same way with a telephone call to the QIO, and from there, the QIO will contact the provider. We'll be asking for that provider to send us certain elements from the patients’ medical records; once we receive them, we will prepare those records. They'll go out to a physician who is not a paid employee of Kepro and is currently in active practice, meaning they see patients at least 20 hours a week, and those physicians will then determine, based upon the documentation in the medical record, meaning what is written in the medical record, he or she will determine whether or not that patient is ready for the next level of care.
Great. Thank you for that very detailed description, Cheryl. So to just kind of synopsize all of this and put it together, so an appeal, in essence, is a benefit to the family that or to the person who's in that type of health care setting that they can have a safe discharge and that they can be ready to thrive again or show some improvement. Is that correct?
I would say that is a fairly accurate summary of it; yes, we want to make sure that that patient is ready for that next level of care, whatever that next level might be; it might be going home from a hospital with home health services; it might be going home and families taking care of it, taking care of them. It might be that they're discharged, and they don't need any additional follow-up care.
OK, great. Understood. And to give the listeners a little bit of an example, I did put something together here as a as a sort of an example case. So please add to this if you have anything to add. So a beneficiary's wife, obviously a Medicare beneficiary to Kepro, is the folks that are the recipient of Medicare, so that's the terminology that we use. So a beneficiary's wife was concerned about her husband's hospital discharge.
She was going to be taking care of him, kind of alluding to what Cheryl said, at home and was concerned about her ability to do that. So even with a planned home health service, which is also what Cheryl mentioned, she wasn't sure that she was ready to see him go home yet. So in that case, and in what Cheryl has talked about through the appeal process, those folks would be able to sort of delay that process until that safe discharge to Cheryl mentioned was able to take place. Is that correct Cheryl?
OK. And you know some of the benefits for the patient in that particular case is that they're financially protected from immediate discharge and potentially having to go back into the hospital for too quick of a discharge, and it also gives them the ability to stay longer at that particular care setting. So to your point, Cheryl, whatever level they're at, whether it's hospital, a nursing home, whatever it be, it allows them to stay a little bit longer if needed through that review process that Cheryl mentioned with the physicians where we're able to say, you know, that person could probably use a couple more days to stabilize and to be more sure, and their family to be more sure, of taking care of them that way.
Well, great. Thanks, Cheryl. I appreciate the description on the appeals.
So the other thing that is a big buzzword out in health care and in medical terms now is quality, quality of people's care. So that is also something that the QIOs do, that Kepro does, and that is take care of quality of care concerns and perform medical record reviews. So to give an example of that, I'll give an example, and then Cheryl if you could add some details and maybe some of the outcomes of these things.
So a person with Medicare went to the emergency department with a stroke or stroke symptoms. From there, there was a delay in their treatment. The timing for proper medication was missed and as we know, you know Cheryl being a nurse by trade, as you know, timing for proper care with a stroke is definitely important, but that proper medication being missed and the symptoms actually worsened. The person with Medicare felt that if the treatment had started sooner, the outcome would have been better.
So Cheryl, in a case like that, could you maybe, you know, tell a little bit about what we might be looking at as far as a an outcome? I mean not necessarily a punitive process, but a way to improve overall quality of care for that person and how we could kind of approach that from a detail standpoint.
We'll certainly Scott, in the situation that you just described, the patient or their representative could certainly reach out to the BFCC-QIO and talk about the scenario, talk about what happened in that particular case. In the description, it certainly seems as though that medications were missed; perhaps the timeline for giving those very critical medications was missed or, you know, could have been delayed, or maybe they missed them all together.
That would be information that we would be able to see within the medical record. We would be able to see when the physician ordered it; we would be able to see when the medications were given to the patient, and from that, our physician reviewers can determine whether or not that care met professionally recognized standards of care. And that's really what we're looking at. Does the documentation of the care meet professionally recognized standards of care?
If they do not, then we as the BFCC-QIO do have to work with that provider to ensure that future care is not negatively impacted by a delay in the administration of the medications. So we'll work with that facility. In regards to that, we're going to look at it from a quality improvement perspective, meaning we'll talk with them about what our results found. And then what within the facility can be done to reduce the time frame from when those medications were ordered and when they were actually given.
We do generally do not have a punitive nature. We are a quality improvement organization as our title states. And so our goal is to look at the care that was provided and then see what can be done at the facility level to ensure that future care meets all professionally recognized standards of care.
Wonderful. So do you have any recommendations for people when it comes to this type of a of a thing, I mean, as far as being concerned about the quality of care. Is there a timing element in in your mind? Cheryl, should people do this sooner rather than later, or is it something that they can do at any point during the process, to bring up these concerns?
Well, there is a time element associated with it. Obviously, the sooner that we are involved with care that may not have met professionally standards, then we have the ability to positively impact future care. That being said, the federal government has provided time frames for when we can look at care. So for a medical record review, the care that is concerning to the Medicare beneficiary has to be reported for, for lack of a better term, to the QIO within three years from the date of service where this care was provided. So if in your scenario, you know that care was rendered in November of 2021, then we would have to be notified of that care or that concern no later than November of 2024, and again, as I've said, the sooner the better to call us. We do have toll-free lines that are available to all Medicare beneficiaries and their families. They can call us. Seven days a week, 365 days a year. Those lines are staffed to be answered by live individuals from 9:00 am in the morning until 5:00 pm in the local time zone.
And after hours, we do have a voicemail capacity to receive those messages, and then we'll return those calls the following day. So it's really important for the Medicare beneficiary and their family when they have those types of concerns to just reach out and call us as quickly as they can, so that we can be as proactive as possible.
That's great information. Thanks, Cheryl, and it's probably a good time to bring up a couple of other points for our listeners and that is that all of the information that that we've discussed to this point and what we'll discuss about Immediate Advocacy here in just a couple minutes is available on our website, and that is keproqio.com, that is keproqio.com and when Cheryl's talking about medical records, for example, that's also a location for healthcare providers, if they do happen to be listening, to realize that they can also submit medical records through that website; we have a process for that as well as detailed explanations about all of these various services that we offer, and we have an interactive map that gives those phone numbers to Cheryl mentioned. You can hover over your state to get the phone number and other information. But if you actually click on the state that you are in, it will provide you with state level resources as well that might be helpful to people in that audience to help them through whatever situation they're in.
So Cheryl, we've talked a little bit about appeals. We've talked a little bit about quality of care concerns.
The third and final topic for today's podcast is one I think that is a newer one that we offer within Kepro, but to me, I think it's one of the most exciting because to me when I say the title, it really is what it means, and that is Immediate Advocacy. It is an immediate ability to advocate on behalf of the person contacting us, to take advantage of their Medicare benefits and to really just help them out and that's anything wide ranging from helping them to locate homecare, looking for gaps in ways that they may have went from skill level to skill level that Cheryl has mentioned. So I'll give a little bit of an example here of that. And then Cheryl, we can kind of talk a little bit more about Immediate Advocacy.
So in the example here, a Medicare patient’s husband called Kepro with concerns about his wife's discharge from a skilled nursing facility. After a care conference with the surgeon, it was determined that the patient's husband was capable of taking care of his wife with home health services; however, once the wife was home, he had questions, so he called Kepro for help with understanding the plan of care and the treatment options. So at that point in time, he was in contact with what we refer to as a clinical care coordinator at Kepro. And that clinical care coordinator then worked with the skilled nursing facility social worker to schedule a 3-way conference call with the home health agency, the social worker, and the patient's husband. So in a sense, sure, we're talking easing people's minds here, and the other portion of this is that the meeting gave that patient's husband a chance to ask follow-up questions, to help both him and his wife to better understand that overall plan of care and now being comfortable with those next steps for continued treatment that allowed them to go forward in that safe environment that you mentioned a little while ago and as well the Kepro Clinical Care Coordinator followed up with that husband to make sure that he felt confident after all of that going forward.
So you know the benefits of that are quicker problem resolution, sort of being a go between or a mediator, getting all the parties to the table and also the provider being more responsive to us in Kepro versus just sending medical records and then having to have someone look at it and it being a little bit of a longer process. Cheryl, I think that the Immediate Advocacy is just that; it's an immediate situation that really helps out people that just may not be confident or may not be in the know, so to speak, on some of their care. Would you feel that that's accurate and anything to add?
I think that is very accurate description, Scott.
And just to add to that, many times people who are in those situations where either they or a loved one is going to be discharged either out of a hospital or even, you know care in the skilled nursing facility is coming to an end. It's a really stressful time. There's a lot of questions that people may have, but they don't really know how to ask them, and they may not even know what's the right person to ask.
So you know, by getting in touch with us quickly our coordinators can, with permission of the beneficiary and permission of the provider, can coordinate a call between all parties and just to open up the lines of communication, so that that individual, that husband, that wife, feel comfortable asking questions, be comfortable knowing that home health has been arranged and they're scheduled to be there on such and such a date. If they have not already arrived. So it's name is very appropriate, it's Immediate Advocacy. That's what we're doing. We're advocating on behalf of the Medicare beneficiary and/or their representative, and we're hopefully providing a conduit for discussion, for dialogue.
Now this can be done on many different situations. It's not just for a discharge. You know, when individuals have questions about the care that they have received, or maybe they feel they didn't get the care that they received, they can call us and they can call through those toll-free lines, and our team will talk with them and they'll our team will, along with the beneficiary or the family member, will work as to what's the best resolution here.
Now for Immediate Advocacy to kind of fulfill its name of being immediate, the federal government has said that we have to, if there's a verbal complaint about care, it has to be within six months of that care being given. So remember medical record review, tt had to be within three years, Immediate Advocacy, it has to be within six months, so that we can be able to help that beneficiary much quicker.
That's great, Cheryl. Good points. And you know as you stated, immediate being in the word, I mean that to me is one of the most important elements of our offerings as well that we can actually get this done for folks a little bit quicker than some of the appeals and quality of care concerns that we've taken care of in the past. So you know, personally I think this is a great offering out to the Medicare folks that they can actually have this benefit as part of the toolkit for their care as well.
So Cheryl, in closing today, do you have anything else you'd like to add for the audience outside of what we've provided to them today?
Just as a closing reminder to all of the Medicare beneficiaries and their family members who might be listening to this, Kepro, as the Beneficiary and Family Centered Care Quality Improvement Organization or BFCC-QIO, is here to serve you, is here to help you, is here to answer any questions that you might have, and so we encourage you to take advantage of your Medicare rights and know that there's a company here that's willing to serve you in whatever capacity is needed.
Absolutely. I couldn't agree more, Cheryl, one of the things that I love about our organization and the folks, such as Cheryl, that work with it is just the passion they have for people's healthcare, just wanting to make sure that people get the right care, the right time, the right way, and help them navigate through some of the complexities of what everybody goes through in a situation when it arises because, we all know Cheryl, it can be a very stressful thing for the person getting care, for the situation that occurred, for their family, for whoever's taking care of them, and you know, as Cheryl said, that's what Kepro is here for is to be an agent of hopefully calm and understanding to try and help through some of these difficulties that people encounter with their health hcare. So it's been great talking with you today, Cheryl, about this. So for everyone listening, I would urge you to go to our website once again.
It's got a great amount of information; it's got ways to contact us. It's also got a lot of resources out there that will tell people things about the way we approach this as well as some helpful things for your health and for working with healthcare providers. And again, that is keproqio.com. That is keproqio.com, that's a a lot of O's there, but again, keproqio.com would be your resource to find phone numbers to reach us, to find emails. We also have a case status tool where people once they do have something started with us, you can check that remotely, and you don't have to necessarily call in again and be on the phone. You can check that through the website. So I would urge people to do that. I would also ask if you're listening to this, that you could tell a couple friends about this, we'd love to be able to provide information to people that is useful to them for this type of a purpose. So please tell everyone you know about keproqio.com and about our podcasts. We're excited. We've got a series of podcasts coming up, and we will be putting our second one out here very soon. So I'd urge you to take a look at that again. Cheryl, one last time, really appreciate you coming on with me today and talking to our audience about ways that they can look out for their health care a little better.
It's been my pleasure, Scott. Thanks so much for having me.
Thank you. And everyone take care, and we hope to see or hear from you or listen to us on our next podcast. Thanks, and I hope you all have a great day.