How the Appeals Medical Record Review Process Works

SUMMARY
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.

This episode talks about how the appeals medical record review process works. We have two guests today, who work at Kepro, Dr. Jessica Whitley, who is the Chief Medical Officer, and Rose Hartnett, the Director of Operations in the appeals department.

For more information about Kepro BFCC-QIO, please visit www.keproqio.com.

KEY TOPICS
01:58: Overview, introduction.
02:30: What is a medical record review and how the process works.
06:35: How you can be more engaged in your health care.
12:30: Things peer reviewers are looking for when they make determinations.
18:40: Getting your questions answered.
19:10: How Immediate Advocacy can help you, if your appeal is denied.

SUBSCRIBE
Subscribe to our newsletters: Case Review Connections, On the Healthcare Front

RESOURCES

• Read about appeals: https://keproqio.com/bene/appeal.aspx
• Watch a video about appeals: www.youtu.be/9q2TKqX0N6k
• Immediate Advocacy services: www.keproqio.com/ImmediateAdvocacy
• Information for stakeholders: www.keproqio.com/partners
• Information for people who have Medicare: www.keproqio.com/bene

Music: Motivational Upbeat Corporate by RinkevichMusic
https://soundcloud.com/rinkevichmusic
Video Link: https://youtu.be/U78mgVaM12M

Transcript

Jana
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. 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.

Kia Weaver
Hi everyone. Welcome to Kepro’s podcast, Aging Health Matters. My name is Kia Weaver, and I'm an Outreach Specialist with Kepro. And I'll be your host today. For those of you who are new listeners, Kepro is the BFCC-QIO for 29 states. Kepro provides services to Medicare beneficiaries as well as those with Medicare as a secondary insurance.

These services include beneficiary complaints, discharge and skilled service termination appeals, and Immediate Advocacy. Today, we will be discussing how the appeals medical record review process works. We have two guests today. We have Dr. Jessica Whitley, who is the Chief Medical Officer, and we also have Rose Hartnett, the Director of Operations in Appeals. Rose and Dr. Whitley, can you please each share a little bit about your background and your role at Kepro?

Jessica Whitley
Thank you so much, Kia. So yes, my name is Dr. Jessica Whitley. I am board certified in Internal Medicine. I've actually been with Kepro since 2012, and I love patient advocacy, and I have a passion for quality of care. So this has just been a wonderful job for me. I do still practice on a very part time basis. I practice as what they call a hospitalist physician. That means I only take care of patients in the hospital. That's about a little bit about me, Rose. I'll pass it to you.

Rosemarie Hartnett
Thank you. Hi, I am Rose Hartnett. I'm the Director of Operations for the Appeals department. I am a registered nurse, and I have worked in hospital settings, home care, telephonic disease management, and case review. And I've been at Kepro for about 6 1/2 years now.

Kia Weaver
Perfect. Thank you to the both of you for being here today, and we can go ahead and jump right in. So Kepro processes hospital discharge and skilled service termination appeals, which both involve a medical record review. Can one of you please tell us what a medical record review is, and how the process works?

Rosemarie Hartnett
I can handle that part of it. So for the appeal process, we can start with acute care reviews, which would be if a beneficiary is in the hospital setting, and they are admitted as an inpatient; they have the right to appeal their discharge if they feel they're not ready to go home or to move to the next level of care.

The hospital will give a notice called the Important Message, and that has Kepro's phone number on it. And once the beneficiary calls us and files the appeal, we contact the hospital, and if they have a Medicare Advantage health plan, we contact them too, and we let them know that there is an appeal, and we request the medical records; so our physicians can determine if you're ready for discharge. When we request the records, the hospital would have until noon the day after you've called us to get us the records. They can securely upload records into our system, or they can send them via fax.

And then it begins the review process. For post-acute care, which would be if a beneficiary is in a skilled nursing facility, home health, or hospice, those providers are also required to give you a notice, and that notice is called the Notice of Medicare Non-Coverage. They have to give that at least two days before they want to discharge a beneficiary. Again, our phone number will be on that notice for you to call and start an appeal. The provider must include an effective date on that, and that would be the last day covered. So beneficiaries must call in and request an appeal by noon the day before the effective date in order for it to be a timely appeal. If you call in after that and you have a Medicare Advantage health plan, Kepro cannot do the appeal. It must be done by the health plan, and we will call you and let you know that.

If you do not have a Medicare Advantage health plan, we can do a review even if you've called in late, but they are not considered expedited reviews, and they can take up to 14 days. So when we receive the call from the beneficiary, we do notify the provider, same as with the hospital. We would request medical records, and the provider has until the close of business that day to get us the records.

For both acute and post-acute care, we will call you with the physician’s determination and let you know the next steps. If the physician agrees with the notice and thinks you're ready for discharge or the next level of care, we will let you know the last covered day and when financial liability could begin If you do not discharge. We  will also let you know your rights for a second level of appeal and ask if you want to start that reconsideration appeal. If our physician felt your care should continue, the hospital or the post-acute provider will continue services, and they will have to issue you a new notice. And then start the process again. And whether you're in the hospital or in post-acute setting, you'll receive a letter from Kepro with the reason for our decision. And the provider also receives a copy of that letter. I  hope that covers everything. Did I miss anything Kia for the process?

Kia Weaver
Nope, that sounds great. Thank you so much.

Rosemarie Hartnett
Sure.

Kia Weaver
Dr. Whitley, did you have anything to add?

Jessica Whitley
I would love to add something; so Rose talked a lot about the process, here are the dates, here's what has to happen. But what I want to talk about for the Medicare beneficiaries or their caregivers or family and friends is that what we do is we look at the medical record. When we get the medical record, the medical record is sent out to physicians that are actively practicing, so they're not retired physicians. They are physicians that are actively taking care of patients, and they review the information in the medical record. So I want to help anybody that may be listening because what goes in that medical record, you want to be a part of that. You want to be actively engaged in your health care. What do I mean by that? So when you're admitted to the hospital, you want to know, OK, why am I admitted to the hospital?

What's going on here? You present with your symptoms, you ask. OK, what do you think is causing these symptoms? And what's your treatment plan? And then what are your goals for me to say OK, your treatment plan has been effective. And you really want to be having these conversations every day with the healthcare professionals that are taking care of you. You want to know what's going on with you, why you're in a hospital, what treatments they're giving you, and what are their goals for care? Because you really should not be surprised at, OK, we're going to discharge you today. Let's take, for instance, you're admitted with pneumonia. OK, you have a pneumonia. These are the antibiotics that we're going to treat you with. That's going to get control of the infection. Our goals are for you to not have any oxygen requirements. And this is, of course, not for every situation, but this is just a loose example.

Our goals would be for you not to have any oxygen requirements, for you not to have any fevers for at least 24 hours, and for you to be able to make sure that you can take your food and take your medicine without any nausea and vomiting. And once we get to that point, we think that you can continue any treatment at home. It's important to know that you don't have to be in a hospital until you're 100% better.

Some things you have to be in the hospital for, but once you get to a certain point, you can continue treatment and go home, but there's certain marks that you must hit. There are certain goals that have to be met before you're safe enough to go home, so make sure you're involving yourself in those conversations on a daily basis. A discharge should not surprise you. This is the same when it comes to if you're staying in a skilled nursing facility after a hospital discharge. 

Say for instance, you're in the hospital; we'll keep going with the pneumonia example; you're in the hospital. You had a bad pneumonia. So say you were in the hospital for a week and because you hadn't really been moving around, you've been in a hospital bed; You're now a lot weaker than what you were when you went in the hospital. So they recommend that you go to a skilled nursing facility to help with rehab, and physical therapy is going to work with you to build up your strength, so that you're safe enough to go home. Again, we're starting with what are the goals? 

Usually if you're having trouble sitting up in bed or if you're having trouble walking, then those therapists should say our goals are to get you to be able to walk this distance, or our goals are to get you to be able to move around in the bed without any assistance or be able to sit up in bed without help and stand without any assistance. So you always want to ask, what are you treating me for? How are you going to treat me? And what are your goals that we're trying to get to?

And you should have that conversation. How are we moving towards our goals? One other thing that I want to emphasize, when you call Kepro with an appeal and you're calling because if you appeal, you feel like you're not ready for those services to be continued. If you're in the inpatient setting, you don't feel like you should be discharged from that inpatient setting to whatever the next level may be. It may be to home, it could be to a skilled nursing facility, but you don't feel that you're ready to leave the hospital.

Please give us details as to why.  We're going to go back to my pneumonia example, but there are plenty of others. But say for instance, you call, you say they're discharging me from the hospital. I don't feel like I'm ready to go home because I still have a fever, or I don't feel like I'm ready to go home because I've been vomiting. They want me to take medicine when I get home, and I'm not going to be able to hold down that medicine. So that type of information really helps us when we give the medical record to the physician. They help to understand this is your voice, and you want to make sure your voice is heard.

The same thing happens in a skilled nursing facility. If we get an appeal a lot of times beneficiaries just simply tell us, I just don't think that I'm ready to go. Tell us why. If you say I can't get out of the bed without having two people to help me up. I was able to walk around my house with no problems. Now I can't even walk to the bathroom because I'm too weak. So please give as many specifics as you can.

Be very involved, know what's going on, know what the goals of treatment are. People may not volunteer to give you this type of information. Do not be afraid to ask. This is your body and your health. Back to you Kia.

Kia Weaver
Thanks so much for that, Dr. Whitley, it's so important for us all to be involved in our own care plan and to make sure that we have a voice. So thanks for adding that. And to go along with that, just so our beneficiaries are aware, what type of things are the peer reviewers looking for when they're making their determinations?

Jessica Whitley
I'm so glad that you asked that. So when we get an appeal and it depends upon what setting of care a beneficiary is in because Medicare has not stringent guidelines, but there are guidelines that Medicare has to determine if a patient qualifies for Medicare payment for those services. All of these guidelines are publicly available. They have Medicare's website, cms.gov, and they have their online manuals, and the manuals that we look at for all of these different types of settings of care.

It's in the Medicare benefit policy manual. So for instance, if you're in the inpatient hospital, then your clinical condition must be one that you need the continuous monitoring that can only be done in a hospital setting, and that you're receiving treatment that can only be done in a hospital setting. We know that we all get sick sometimes, and that doesn't mean we have to be in a hospital, but sometimes we get sick to the point that we do need to be taken care of in the hospital, so the physicians are going to look at the type of setting. In the inpatient setting, they're going to look at the patient’s clinical condition. They're going to look at why the patient came into the hospital, what were the presenting complaints, what did the doctors feel like the diagnosis is, what did they do to treat the patient, what goals does the patient have to reach before they can be discharged home. Are they going to be safe being discharged to home? And so that's the kind of things that they are looking at through the medical record. 

It is important to note that we don't have conversations with the physicians that are taking care of the patient. We rely on a medical record review, and that's why earlier I made the comment to make sure you're having these conversations with your physician on a daily basis because that could influence what is being put in the medical record. If you have concerns, make sure you voice those concerns, and then the physicians can say patient is concerned about this, patient has this new pain, and that's able to be seen in the medical record. Now when you talk about care like in a skilled nursing facility or in home health, there are also guidelines that determine whether or not Medicare beneficiaries are eligible for Medicare payment for those services.

And it really relies and rests on medical necessity. I know that that's probably a term that sounds a little bit confusing, so let me break that down. When you have something that needs to be treated, there are multiple ways that a treatment can occur. There are multiple places that a treatment can occur. Medicare is looking for where can we treat this that you will achieve the same outcome in the most efficient way possible. 

We wouldn't want to bring everybody that has a simple cold into the hospital. Can you treat a cold in the hospital? Yes. But can you treat a cold equally as effective in the home? Yes, you can. When we're talking about services in a skilled nursing facility, when we're trying to build up strength, there's a certain level of weakness where you may not be safe to go home. And so you need to be in that inpatient setting in a skilled nursing facility where you have people monitoring you daily and throughout the day and you're getting therapy daily, but you can get to a point that your strength has built up to the point where you may not be where you were before the onset of your illness, but you're safe enough to go home and perhaps receive home health care. 

And that's going to come maybe three days a week in the home, and you can achieve the same benefit of building up your strength again, but you may not have to be in that skilled nursing facility setting. So when our doctors are looking in these records, they're looking to see, OK, what's the patient’s condition, how are they doing at the point that we're doing the review, what's the goals of care, and where do we need to get that patient to in order to safely allow them to go to the next level of care?

If it's inpatient, that could be home or to a nursing home facility. If you're in a skilled nursing facility, that could be home with home health care, or things like that or could be home, and you may not need home health care.

Does that help, Kia?

Kia Weaver
Yes, that's perfect. Actually, one of my follow-up questions was going to be the qualifications of the peer reviewers, but you mentioned they’re doctors, so that was great. Thank you so much for that.

Jessica Whitley
And Kia, what I will add is we don't just look for any doctors, we look for doctors that are board certified. When we say they have to be actively practicing, that means on average they need to be seeing patients 20 hours a week, and they have to have the expertise to look at these types of reviews; for instance, we don't have radiologists looking at hospital care for patients because radiologists are experts at looking at x-rays and other kind of fields; we have physicians that are actually doing the type of care that they are evaluating. So not only do we use physicians, but we use physicians with the expertise to evaluate the type of care that patients are receiving.

Kia Weaver
Perfect. Thank you so much for making that clarification.

And that was all the questions that I had for you two today. Is there anything else that you would like to share? Rose, you have anything else that you like to share?

Rosemarie Hartnett
The only thing I would say is that if a beneficiary or their family has any questions at all about the appeal process before, during, or after, they can always call Kepro; our call center representatives can answer most of their questions, and if they cannot, we will have a nurse call you back with any specific or detailed information that you need.

Jessica Whitley
And Kia, I would also add to that if ever you feel like you've called for an appeal and you didn't win your appeal or we said yes, you're safe enough to go to the next level, and you're concerned about that decision; you're concerned about if you have the proper equipment in the house. We do have what we call Immediate Advocacy, and that allows you to talk to a nurse that can try to help you, to arrange follow-up appointments, to make sure you have access to get medications, to make sure you have any equipment that you may need in the house, so please make sure you avail yourself of that opportunity. 

Also, if ever you think something has not been looked at or you're very confused about the decision, you can always call us back and say hey I am concerned about this decision; here's why I'm concerned about this decision. Can you pass this on to a supervisor to take a look at? We're here to serve the beneficiaries, and we take our jobs very seriously.

And also, all beneficiaries, all caregivers out there, don't forget, advocate for yourself. Don't wait for people to give you information. Ask for the information, understand what's going on with your own health. Know what your goals of care are, know what medications you need to take, know why you're taking it, and what you're trying to achieve. We can't do it without you. The doctors are here, but we need you to be active participants in your health care and it's going to improve your health care, I guarantee you. So thank you.

Kia Weaver
Thank you so much to the both of you. Thank you for taking the time out to discuss the medical record review process with us. I'm sure it's been extremely beneficial for our listeners, and I've even learned a few things too. So thank you so much. Dr. Whitley did briefly mention Immediate Advocacy. I wanted to point out that we have discussed this service in detail in previous episodes, and further information can be found on our website as well. If you've enjoyed this episode and would like to hear more about the services that Kepro offers, the partners that we work with, and so much more, please stay tuned for our next episode.

Please also feel free to sign up for our newsletter and subscribe to our YouTube channel. Information about our newsletter and YouTube channel can be found on our website, and we are constantly updating our website to reflect any changes or updates to inform our partners and the Medicare beneficiaries that we serve. And again, our website is www.keproqio.com, so please feel free to check that out. Thank you and please tune into our next episode.