Conversation with the QIO/BFCC-QIO 101 for Healthcare Providers Ask-the-Contractor Teleconference (ACT) - September 29, 2022
View the handout for the September 29, 2022, ACT event. Please note only questions relevant to the topic are posted.
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- I would like clarification as the QIO accepts appeals well after midnight after the day of discharge.
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KEPRO will not deny anyone appeal rights if the appeal is called in after midnight. When a Beneficiary calls a hospital discharge appeal into KEPRO after midnight, if the Physician Review agrees with the decision the date of liability will revert back to the date the discharge order was placed, or the Important Message was issued whichever is the latter.
Livanta added, the appeal is initiated/accepted according to the time parameters that appear on the discharge notice. That's why patients are urged to file their appeal as soon as possible. That time frame will vary from beneficiary to beneficiary, depending on what the care facility has determined as the beneficiary's last day of coverage. If the patient waits too long to initiate an appeal, and goes beyond that window, his appeal won't be accepted.
Published: 10.26.22
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- Would like to discuss "how are they responsible" especially if they have a managed Medicare plan.
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More information needed to fully address this concern. However, maybe this will help. When a patient receives his discharge notice/notice of non-coverage, he has a window of time in which to file an appeal of discharge. If he files an appeal within that timeframe, he is NOT financially responsible for care received during the time that his appeal is being determined, and his discharge is paused until the Physician Reviewer has made a decision on his appeal. If the appeal is ruled in his favor, he can stay in the care facility and will not be financially responsible for care. If the Physician Reviewer agrees that the person should be discharged, the patient will be financially responsible for all care received STARTING FROM THE TIME HE RECEIVES HIS APPEAL DECISION. So, during that time that his appeal is being decided, (typically 24-48 hours) he's not obligated to pay. Once he and the care facility have gotten notification that his appeal has been denied, he's financially responsible for all costs going forward from that time. He does not have to pay care costs for the time the appeal was being decided. Please contact the QIO for your area if additional clarification is needed.
Published: 10.26.22
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- Why is the Hinn12 optional?
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The HINN 12 is not optional. It should be issued to the Beneficiary if KEPRO renders an agree decision to notify the Beneficiary and/or their Representative of any liability that they could be facing if they do not discharge by 12noon following the day. Livanta agrees.
Published: 10.26.22
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- If a patient appeals a decision by hospice to discharge them from services because they are no longer medically eligible for hospice care and the QIO disagrees with our decision, what happens from the QIO perspective if the hospice refuses to keep the patient on service? Note that we've been told explicitly at the most recent CMS Summit that we are not obligated to continue providing care if the hospice IDT believes that the patient is not eligible, and the Hospice MD is unable to certify a terminal illness.
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KEPRO is responsible for making a decision as to whether services should continue or not. KEPRO cannot dictate if the provider has to continue services. Livanta agrees.
Published: 10.26.22
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