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SUMMARY
As a contractor for Medicare, Acentra Health serves as the Beneficiary and Family Centered Care Quality Improvement Organization, also referred to as a BFCC-QIO. While Acentra Health 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 is a conversation with our guests from Acentra Health: Cheryl Cook, Program Director, Rose Hartnett, Operations Director for Appeals, and David Miller, Operations Director for Quality of Care and Immediate Advocacy. 

In this podcast, our guests will share information about the free services available from Acentra Health.  

For more information about Acentra Health BFCC-QIO, please visit www.acentraqio.com. 

KEY TOPICS
00:23: Overview, introduction of guests 
01:57: General information about the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) 
05:47: Acentra Health’s appeal process 
08:36: New Immediate Advocacy Discharge Assistance (IADA) program 
13:12: Quality of Care complaints and the Immediate Advocacy process 
20:00: Case Status tool 
21:18: Summary and final thoughts 

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

RESOURCES
BFCC-QIO Information for stakeholders: www.acentraqio.com/partners
BFCC-QIO Information for people who have Medicare: www.acentraqio.com/bene
YouTube channel 

Music: Motivational Upbeat Corporate by RinkevichMusic https://soundcloud.com/rinkevichmusic
https://protunes.net/  
Video Link: https://bit.ly/3NNqGTs 

Transcript

Welcome to Aging Health Matters, a podcast from Acentra Health, 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.  

Scott Fortin    
Hello everyone and welcome to another edition of Aging Health Matters, a podcast from Acentra Health. Our podcast today is centered around the work of the BFCC- QIO, a Beneficiary and Family Centered Care Quality Improvement Organization. Just to refresh a little bit from previous podcasts, there are two contractors that take care of this work throughout the nation. Acentra Health has 29 of those, and we recently just started some new exciting elements. We have a new scope of work that is revised from previous work, including a couple of new features which we'll talk about today for the next five years. And we also transitioned to our new name, Acentra Health, from our parent company, from Kepro previously. 

 So we do have three key services that we offer to people as part of our work under our contract with the Centers for Medicare & Medicaid Services. And that's the point of what we're here to talk about today. You can learn more about these things on our website at www.acentraqio.com, but for now, I'd like to introduce our guests. So this is the largest podcast that we've ever had as far as our number of guests, I'm very happy to have some of my colleagues with me today. We have Cheryl Cook, our program director. We also are joined by David Miller and Rose Hartnett, who are going to tell you more about many of our processes and a lot of our work. So welcome, everybody. Could you tell the audience a little bit about yourself, your background, how long you've been with Acentra Health? 

Cheryl Cook    
Well, greetings Scott. This is Cheryl Cook, and I have been with Acentra Health 
since 2014. I've been in the QIO program since 2001. 

Scott Fortin    
Great. Thanks Cheryl. 

Rosemarie Hartnett    
Hi, Scott. This is Rose Hartnett. I am the Director of the appeals department for the QIO, and I've been at Acentra Heatlh for eight years now, and I am an RN. 

Scott Fortin   
Great. Thanks Rose, and David. 

David Miller    
And last but not least, I'm David Miller. I am an Operations Director with Acentra Health. I've been with the organization for a little over seven years, and much like Rose and Cheryl, I am an RN by background. 

Scott Fortin    
Great. Thank you to all three of you, and that is one of the things that I do enjoy the most about my colleagues is that they are all registered nurses and are very knowledgeable due to their time in and outside of this program and health care. 
So with that, let's jump into some of the things that we do. Cheryl, is there anything you'd like to give us as far as a generalization about some of the work that we do?  Some of the processes and advocacy-type things before we dive deeper into things with David and Rose. 

Cheryl Cook    
Certainly, Scott, would be happy to. The Beneficiary and Family Centered Care Quality Improvement Organization is a colleague of the Medicare program, and it is designed to protect Medicare beneficiaries' rights and also to protect the Medicare program itself. We talk about protecting rights. We want to make sure that the Medicare beneficiaries themselves receive care, healthcare services, that meet professionally recognized standards. 

We also protect their rights to an expedited review, whether that's related to the quality of care that they have received or related to a pending hospital discharge or the termination of skilled services. And then lastly, we help protect the physical integrity of the Medicare Trust fund by making sure that Medicare only pays for those services that are medically necessary and provided in the most appropriate settings. We do all of those activities through a number of different mandated reviews, some of which David and Rose are going to talk about in greater detail. But overall, we respond to the Medicare beneficiary and/or their family members concerns about the quality of healthcare services that they received. We can do that through a number of different ways, through a medical record review or to do some advocacy work between the Medicare beneficiary and the provider. 

We also do a number of reviews that are appeals that are related to those pending hospital discharges I mentioned or the termination of skilled services in post-acute settings like home health, a skilled nursing facility or in outpatient rehab. And then we also do some work that provides information back to the Medicare program themselves through our EMTALA reviews. That is a review that we provide information back to the Medicare program regarding patients who come into an emergency room for care and whether or not that hospital follows the appropriate guidelines that are outlined in federal law. So that’s kind of really a broad view of the work that we do, and my colleagues are certainly going to go into more detail on some of those different types of reviews. 

Scott Fortin   
Great. Thank you. I really appreciate that explanation. I think that really gets to a lot of the details of our work in a in a way that a lot of people can easily understand. 
So thank you for that. One of the things that Cheryl mentioned is the appeals process, David and Rose. Would one of you like to handle that one? 

Rosemarie Hartnett   
Sure, I can do that, Scott. As Cheryl said, Medicare beneficiaries have a right to an appeal if they feel they are getting discharged from the hospital too early, or they're in a post-acute setting like a skilled nursing facility or in home care, and their skilled services are ending. What happens for Medicare beneficiaries is they will receive a notice from the healthcare provider that states the date that they want to discharge the beneficiary or stop the skilled services. And when financial liability would begin for the beneficiary if they did remain. There's also a notice called a hospital-issued notice of coverage. That's for patients when the hospital thinks that Medicare is not likely to pay for the admission to the hospital. The rest of the appeals we do are for discharges.  

So I can talk a little bit about the process for beneficiaries when they contact Acentra Health to file an appeal. The beneficiary or their family member or representative calls Acentra Health, and our call center representative will take some information about the healthcare provider and if you have a Medicare Advantage plan or original Medicare. They will ask the beneficiary why they want the appeal. That's important because our physician reviewers do want to know why you feel you're not ready for discharge or for the next level of care. We then notify the provider and the health plan, if you have one, of your appeal, and we request the medical records for review. 

We do have independent physicians who review your case, and they make the decision, and then Acentra Health will notify you, the healthcare provider, and the health plan of the physician’s decision. If the physician felt that you should continue services or not be discharged from the hospital, you get to continue services until you are issued another notice by the provider. They will give you another notice with a new date of discharge and a new date for when financial liability would begin. You are protected from liability if you win your appeal. 

If your appeal is denied, your financial liability begins on the date that's listed on your notice. You can file a reconsideration appeal with Acentra Health, and a second different physician would review your case then. You do not have financial protection during the reconsideration process though, so that's important to know. If you lose the reconsideration appeal, your original liability date is still in effect. And CMS has a new program that I wanted to tell you about related to our hospital discharge appeals. If you have original Medicare and you are being discharged from a hospital and want to file an appeal, if you feel that you need assistance with your discharge, plan, Acentra Health can help with that. Our customer service representative can transfer you to an advocate when you call to file your appeal, and they can assist and speak with the social worker or case manager at the hospital. And David Miller can probably speak more to that. So I think I'll leave it there. 

David Miller    
Thank Rose. That’s a great transition. Much like Rose had said, this is a new program that is offered by Medicare for traditional Medicare beneficiaries only that are coming out of an acute care setting. So basically, you know, out of a hospital, out of a rehab, and much like Rose had indicated, when that appeal is filed, the call center folks within Acentra Health will offer that beneficiary the option of being transferred over to our team of clinicians who are all nurses. 

Basically, what this team will do is discuss the discharge plan with that beneficiary. It does not impact the appeal process. The appeal process will continue independently. This is just kind of an adjunct to look at the discharge process. What is the discharge plan for that beneficiary? Is there anything that we can help to clarify, explain a little bit clearer?  

And really we incorporate the beneficiary and the provider facility, so if you call in with a discharge appeal and you want some assistance with understanding the discharge plan, our team of clinicians can arrange a collaborative phone call between yourself and the provider, the hospital, the case management team that is working with your discharge plan and have a conversation to try to better provide understanding of what that discharge plan entails. It's all verbal. It's all very quickly done. Again, it does not impact the appeal process, but we really try to incorporate this service while the appeal is going on, and we do not impact the timeline of that appeal. But again, really what we want to do is try to provide some clarity behind what that discharge plan entails, just in case there's some confusion or some things that we can work with the hospital provider community and yourself, to really augment that process and get you to the next step quicker. 

Scott Fortin    
Great. Thank you, David and Rose. So just a few things to kind of clarify and a couple of questions that I had that hopefully will benefit the audience. First thing I will say that my colleagues and I utilize the term beneficiary quite a bit. So for those of you out there in the audience wondering if you are a beneficiary, if you are receiving Medicare, yes, you are a beneficiary or a Medicare recipient. 

We do use those terms interchangeably quite a bit. The other thing too that I did want to point out, and please correct me if I'm wrong, any one of the three of you, the discharge assistance, the IADA work, is our latest work and our newest work; everything else we're doing, to Cheryl Cook's point a few minutes ago, is pretty much in concert with what we've done previously. So the new part of our work is the discharge appeals that David Miller just discussed. And from my understanding of it, this is a situation where you can provide rapid assistance to people, to David's point, of getting together as almost like an intermediary to help the process go forward a little bit faster, of getting through the issues that you have with your discharge appeal. Is that correct, David? 

David Miller    
You hit it right on the nose, Scott. I mean, again it does not impact the discharge appeal that goes independently, but it is to really provide that clarification and communication and understanding of the discharge plan to expedite it. And again,  get you to the next point quicker as appropriate. 

Scott Fortin    
Great, wonderful. And that is something that we've pointed out to our audience in a previous podcast in different partnerships that we've discussed and things, and that is that one of the main purposes of our program is to ensure that people have a voice, they're heard, and that we can provide different elements of review for them to ensure that some of their time in the healthcare environment is as good as it possibly could be. Would you guys agree with that or have anything to add to that? 

David Miller    
I think you said it perfectly. 

Scott Fortin   
Wonderful. Thank you. And there's a couple of other things that that I know that we do that I'd like to make sure we explain to the audience. And we also have a beneficiary complaint process and Immediate Advocacy. So if one of you'd like to talk a little bit about describing some of those elements and how people can work through some of the issues that they're having with their care with some of that, that'd be great. 

David Miller   
I can touch on both of them, Scott, thank you. Immediately Advocacy is probably the easiest of the two to really describe. So Immediate Advocacy is a voluntary, verbal interaction, much like we just talked about with the discharge assistance plan. We do a very similar process. The beneficiary or their representative can call in with a concern, and our team of clinicians, now the Immediate Advocacy team is nurses and social workers, and we will look at that concern and have a conversation with the provider community. Much like Scott describing beneficiaries, the provider community can be a hospital or physician, a skilled nursing facility or rehab, home health, anything really that's giving that care. We will have a discussion with whoever that might be. Some of the examples could be: I can't get an appointment with my physician. I'm having difficulty getting my medications. The medication dosages are incorrect. Kind of high-level type things, more so things we will not find in a medical record. 

So it can be something that we can discuss voluntarily between the beneficiary and the provider community and try to come to kind of a rapid resolution with it, really just talk it through, get it done. Really the benefits of this is we can get somebody on the phone, you can have that fast conversation, get to the root of the problem, and really kind of come up with a better mechanism to have care provided, get that appointment, rearrange home health services, or obtain home health services. A lot of things along those lines. So that's kind of the real high-level of Immediate Advocacy. 

The complaint process is a little more in-depth. If there's a complaint of the care that is provided to a beneficiary, they can also call in or their representative and provide that information. You know it can be a procedure wasn't done correctly, and there were some problems after a procedure was done, and the medication dosage was not correct. Maybe there was an allergic reaction to a medication, maybe known allergy, but a medication was still provided. Maybe there were some skin integrity concerns, and various things along those lines. 

Basically, a complaint review is something we would find in a medical record, Immediate Advocacy, we will not find it in a medical record. So basically what happens is the beneficiary or the representative will file that complaint. One of our team of nurses will listen to that complaint, kind of take some verbal and some notes from the conversation. We send a form to the beneficiary or the representative that has a summation of what the concerns are. The beneficiary will acknowledge that that form is correct, sign it, and send it back. Once we receive that signed complaint form back, we will reach out to the provider community and obtain the medical records for the dates of service that are in question. 

If you're in a hospital for a period of time or you were in home health receiving home health services for a period of time, we will look at those medical records against those complaints and try to kind of determine what standards of care, appropriate. standards of care should have been in play during that medical record review. And really kind of go through and look at that medical record review and pull pertinent information out of it. All of that is presented to our independent physician reviewers, and they make that determination based on what do they see in the medical record, how does it match up to the complaint that the beneficiary representative has, and was a standard of care appropriate? Did they receive the appropriate care per processes? Was the complaint valid, and something went awry? So we do provide all that information back. 

One of the really big things to note about this particular review process, it's not punitive. If we find that there's a concern with the provider, that something wasn't quite right, we will work with that provider. We will work with Medicare to have an improvement process, but this is not punitive. We do not have the ability to impose a monetary fine. We cannot put them out of business. We cannot take somebody's license. That is not part of the QIO overview and responsibility, but we really do want to ensure that the care that is being provided to our beneficiary community and much like Cheryl had indicated, is appropriate; it's medically necessary and it's being provided correctly. 

Scott Fortin   
Well, that's great. Thank you, David, for that explanation. And just to sort of recap for people and this is where I definitely always rely upon my colleagues because they have the deep knowledge of these things, just to do a recap for the audience. Both the appeals and the beneficiary complaint process can utilize medical records. Immediate Advocacy cannot. That's correct, right? 

David Miller    
That is correct. 

Scott Fortin    
OK, so the difference in when David was talking about Immediate Advocacy. 
One of the things that came to mind for me is we do have as one of our states Florida, for example, and the southeast portion of the United States as well as areas like Texas. So the thing that comes to my mind sometimes is hurricanes and natural disasters where people are just in a situation where they may not be able to get things they need, whether it is medical equipment, prescriptions, things of that nature. David, would you mind talking for just a moment about how Immediate Advocacy, for example, can help people in a situation with needs such as that? 

David Miller    
Absolutely. That's really a great example, Scott, because we do have, as time and the environment, the weather environment of the country anymore. You're seeing more heat-related concerns and definitely hurricanes and tornadoes in the midwest and such. What Immediate Advocacy can do is really kind of look and help that beneficiary with what is open. What pharmacy was not impacted by that hurricane and is still open and in business, to obtain at least a temporary bridge to medications?

Scott Fortin    
Great. Thanks for the definition of that. A little bit more in the description, and I would be remiss if I did not give a plug for a portion of our website, and that is our Case Status tool. I wondered if one of the three of you would like to tell the audience a little bit more about that Case Status tool and how that fits into the process and how people can get information directly on the web without even having to contact us by phone at times. 

Rosemarie Hartnett    
Sure, I can do that, Scott. The Case Status tool is for appeals, so when you call into our call center to file your appeal, you'll be given a case ID. If you go to our website, you can just put that case ID into the field, and it will show you the status in real time of your case. So it goes through where we have requested the records, where the case is being reviewed by a physician, what the decision was, and when the financial liability date is, when that would be, and when the case is completed. So it is frequently used by Medicare beneficiaries but also the healthcare providers, so they can stay up to date on your case. 

Scott Fortin   
Absolutely. And thanks for the explanation of that Rose. If there's anything else that you would like to share with the audience, what would that be? 

David Miller   
I think just kind of from my point, Scott, Acentra Health has a lot of really great services that we can offer to the Medicare community and really provide great service in ensuring that that care is appropriate. And I really encourage, when a need occurs, please reach out. 

Scott Fortin    
Absolutely. One thing that the team of folks that I work with every day that we always like to describe in every piece of everything that we can put out is the fact that you have rights, and people have heard me say that in some of the YouTube videos that we have online. And that is the description to me, that you have rights, and we have the ability to help you with the tools that this group has talked about today. So with that, anything else that you'd care to talk through before we wrap up?  

All right. Well, I want to take a minute to thank Cheryl, Rose, and David for their time and explanation. Obviously, we have provided a lot of different information and very detailed topics to the audience today, so we really hope that you utilize some of the ways that we interact with you. So if you'd like more information about our services, you have many ways to get information. You can sign up for one of our newsletters. We have one that is aimed towards providers and stakeholders, and one that is towards the Medicare recipient and their family. 

We also have a YouTube channel that I referenced, and that tells you more about some of these items in greater detail if there might be something detail-wise that you might have missed in the podcast. It also provides on our website the helpline phone numbers, and we also have our website and the phone numbers in the Show Notes below. And if you want to sign up for that newsletter or look for the YouTube channel, you can find that in the Show Notes. 

And also, I will point out that we also have two great Outreach Specialists if you happen to be a provider or stakeholder and need further information about some of the things we do in your area in your state. So I just really want to come back and thank you again for taking this time out of your busy schedules to share all this information with our listeners, and thank you to all of you listeners for listening, and I hope that you'll stay tuned for the next episode of Aging Health Matters. Thanks and have a great day.