Changes in the Beneficiary Protection - Case Review Program by CMS

OFMQ would like to take this opportunity to apprise you of forthcoming changes to the QIO program that will impact Oklahoma providers (hospitals, skilled nursing facilities/units, home health/hospice agencies and long term acute care facilities). CMS is in the process of making changes to the QIO program as you know it. CMS has restructured the QIO Program from its historical 53 contracts, in which each QIO performs both case review and quality improvement support for each state or territory, to a regional structure for case review and an industry-determined service structure for quality improvement initiatives.  In the new structure, or the 11th Statement of Work, case review and quality improvement functions will be performed by different contractors, the contract periods will be extended from 3 to 5 years, and there will be an enhanced focus on learning, collaboration and the dissemination of best practices.

Effective 8/1/2014 OFMQ will no longer be performing reviews of any kind (Discharge Appeals, beneficiary complaints, higher weighted DRGs, EMTALA, Sanctions,  referrals for quality of care, nor quality of care reviews) for CMS. CMS has regionalized the review processes that continue to be required by CMS and Federal regulations.

Specific contractors will process  beneficiary complaints while a different contractor will provide technical assistance to support providers and suppliers. QIOs will have new skills in the area of transforming practices, employing lean methodologies, assisting with value based purchasing programs and developing innovative approaches to quality improvement. The Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIO) manage all beneficiary complaints and quality of care reviews to ensure consistency in the review process while taking into consideration local factors important to beneficiaries and their families.

Quality Innovation Network (QIN) QIOs are responsible for working with providers and the community on multiple, data-driven quality initiatives to improve patient safety, reduce harm and improve clinical care at their local and regional levels. These changes to the program were done to restructure and approach the QIO work with a broad range of entities to perform the work to foster innovation, development of learning systems and continuous process improvement. Please see the attached information for details of the revised processes and timelines.

We are informing you of these changes in an effort to provide information that may be of assistance to your organization  to maintain continuity of services to both providers and beneficiaries.

Changes in the QIO Program by CMS

Quality Case Review and Appeals after July 31st 

  • Changes will be taking place on August 1, 2014. KePRO the newly appointed BFCC - QIO will conduct all reviews active as of 7/31/14 and new reviews from 8/1/14 forward. These changes are part of the Centers for Medicare & Medicaid Services (CMS) design to reorganize the Quality Improvement Program (QIO).  The types of cases KePRO will be requesting and reviewing include:
    • Beneficiary complaint cases for quality of care review,
    • Higher Weighted DRG reviews, and
    • Discharge Appeals involving hospital inpatients, home health-hospice, skilled nursing units.
  • If a case is currently in the review process and still active on 7/31/14, please be assured that every effort has been made to ensure a seamless HIPAA secure transition with no disruption in case review services.
  • OFMQ’s Beneficiary Hotline 1-800-522-3414 will be managed and answered by KePRO’s staff for continuation of the same type of services as was provided by the OFMQ review staff.


Maintaining Local Presence

  • The redesign of the QIO program will not lessen the contractual obligation of the QIOs to meet the local needs of their constituents, regardless of geographic factors that are unique to care in the Oklahoma service area.
  • The importance of local QIO work is acknowledged by CMS and will be maintained through Medicare regulations.
  • Work through CMS’s QIO program will be conducted during the next 5 year period with focused projects in:
    • Improving Cardiac Health
    • Improving Diabetes Care
    • Use of Electronic Health Records
    • Reducing Healthcare Associated Infections in Hospitals
    • Reducing Healthcare Associated Infections in Nursing Homes
    • Care Transitions
    • Quality Improvement Initiatives


Contact Information

  • A list of the current BFCC-QIOs and QIN-QIOs for your area, and their contact information, are located at QIOProgram.org.
  • More information on the QIO Program can be found at QIOProgram.org or by contacting 1-800-MEDICARE.
  • KePRO will be the Beneficiary and Family Centered Care QIO for Oklahoma.

    Their address is:
    Rock Run Center
    5700 Lombardo Center, Suite 100
    Seven Hills, Ohio  44131
    Phone: 216.447.9604
                844.430.9504
    Fax: 844.878.7921
     

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