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AREA #1 BFCC-QIO 11TH SOW
ANNUAL MEDICAL SERVICES REPORT08/01/2015 - 07/31/2016
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
TABLE OF CONTENTS TABLE OF CONTENTS ........................................................................................................................................................................... 2
INTRODUCTION: .................................................................................................................................................................................... 1
Livanta QIO Area #1 – Summary ......................................................................................................................................................... 2
1) Total # of Reviews................................................................................................................................................................ 2
2) Top 10 Principal Medical Diagnoses:................................................................................................................................... 3
3) Provider Reviews Settings: ................................................................................................................................................... 4
4) Quality of Care Concerns Confirmed ................................................................................................................................... 5
5) Discharge/Service Termination ............................................................................................................................................ 6
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by
Notification Type ................................................................................................................................................................. 8
7) Evidence Used in Decision-Making ..................................................................................................................................... 9
8) Reviews by Geographic Area ............................................................................................................................................. 13
9) Outreach and Collaboration with Beneficiaries .................................................................................................................. 14
10) Immediate Advocacy Reviews ........................................................................................................................................... 16
11) Example/Success Story ...................................................................................................................................................... 17
12) Beneficiary Helpline Statistics ........................................................................................................................................... 17
CONCLUSION: ....................................................................................................................................................................................... 18
APPENDIX .............................................................................................................................................................................................. 19
Livanta QIO Area #1 – State of Connecticut ...................................................................................................................................... 19
1) Total # of Reviews.............................................................................................................................................................. 19
2) Top 10 Principal Medical Diagnoses .................................................................................................................................. 20
3) Beneficiary Demographics ................................................................................................................................................. 20
4) Provider Reviews Settings .................................................................................................................................................. 21
5) Quality of Care Concerns Confirmed ................................................................................................................................. 22
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by
Notification Type ............................................................................................................................................................... 24
7) Reviews by Geographic Area – Urban and Rural ............................................................................................................... 25
8) Immediate Advocacy Reviews ........................................................................................................................................... 25
Livanta QIO Area #1 – State of Massachusetts................................................................................................................................... 26
1) Total # of Reviews.............................................................................................................................................................. 26
2) Top 10 Principal Medical Diagnoses .................................................................................................................................. 27
3) Beneficiary Demographics ................................................................................................................................................. 27
4) Provider Reviews Settings .................................................................................................................................................. 28
5) Quality of Care Concerns Confirmed ................................................................................................................................. 29
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by
Notification Type ............................................................................................................................................................... 31
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
7) Reviews by Geographic Area – Urban and Rural ............................................................................................................... 32
8) Immediate Advocacy Reviews ........................................................................................................................................... 32
Livanta QIO Area #1 – State of Maine ............................................................................................................................................... 33
1) Total # of Reviews.............................................................................................................................................................. 33
2) Top 10 Principal Medical Diagnoses .................................................................................................................................. 34
3) Beneficiary Demographics ................................................................................................................................................. 35
4) Provider Reviews Settings .................................................................................................................................................. 36
5) Quality of Care Concerns Confirmed ................................................................................................................................. 37
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by
Notification Type ............................................................................................................................................................... 39
7) Reviews by Geographic Area – Urban and Rural ............................................................................................................... 40
8) Immediate Advocacy Reviews ........................................................................................................................................... 40
Livanta QIO Area #1 – State of New Hampshire ................................................................................................................................ 41
9) Total # of Reviews.............................................................................................................................................................. 41
10) Top 10 Principal Medical Diagnoses .................................................................................................................................. 42
11) Beneficiary Demographics ................................................................................................................................................. 42
12) Provider Reviews Settings .................................................................................................................................................. 43
13) Quality of Care Concerns Confirmed ................................................................................................................................. 44
14) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by
Notification Type ............................................................................................................................................................... 46
15) Reviews by Geographic Area – Urban and Rural ............................................................................................................... 47
16) Immediate Advocacy Reviews ........................................................................................................................................... 47
Livanta QIO Area #1 – State of New Jersey ....................................................................................................................................... 48
1) Total # of Reviews.............................................................................................................................................................. 48
2) Top 10 Principal Medical Diagnoses .................................................................................................................................. 49
3) Beneficiary Demographics ................................................................................................................................................. 50
4) Provider Reviews Settings .................................................................................................................................................. 51
5) Quality of Care Concerns Confirmed ................................................................................................................................. 52
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by
Notification Type ............................................................................................................................................................... 54
7) Reviews by Geographic Area – Urban and Rural ............................................................................................................... 55
8) Immediate Advocacy Reviews ........................................................................................................................................... 55
Livanta QIO Area #1 – State of New York ......................................................................................................................................... 56
1) Total # of Reviews.............................................................................................................................................................. 56
2) Top 10 Principal Medical Diagnoses .................................................................................................................................. 57
3) Beneficiary Demographics ................................................................................................................................................. 57
4) Provider Reviews Settings .................................................................................................................................................. 58
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
5) Quality of Care Concerns Confirmed ................................................................................................................................. 59
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by
Notification Type ............................................................................................................................................................... 61
7) Reviews by Geographic Area – Urban and Rural ............................................................................................................... 62
8) Immediate Advocacy Reviews ........................................................................................................................................... 62
Livanta QIO Area #1 – State of Pennsylvania .................................................................................................................................... 63
1) Total # of Reviews.............................................................................................................................................................. 63
2) Top 10 Principal Medical Diagnoses .................................................................................................................................. 64
3) Beneficiary Demographics ................................................................................................................................................. 65
4) Provider Reviews Settings .................................................................................................................................................. 66
5) Quality of Care Concerns Confirmed ................................................................................................................................. 67
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by
Notification Type. .............................................................................................................................................................. 69
7) Reviews by Geographic Area – Urban and Rural ............................................................................................................... 70
8) Immediate Advocacy Reviews ........................................................................................................................................... 70
Livanta QIO Area #1 – Puerto Rico .................................................................................................................................................... 71
1) Total # of Reviews.............................................................................................................................................................. 71
2) Top 10 Principal Medical Diagnoses .................................................................................................................................. 72
3) Beneficiary Demographics ................................................................................................................................................. 73
4) Provider Reviews Settings .................................................................................................................................................. 74
5) Quality of Care Concerns Confirmed ................................................................................................................................. 75
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by
Notification Type ............................................................................................................................................................... 77
7) Reviews by Geographic Area – Urban and Rural ............................................................................................................... 78
8) Immediate Advocacy Reviews ........................................................................................................................................... 78
Livanta QIO Area #1 – State of Rhode Island .................................................................................................................................... 79
1) Total # of Reviews.............................................................................................................................................................. 79
2) Top 10 Principal Medical Diagnoses .................................................................................................................................. 80
3) Beneficiary Demographics ................................................................................................................................................. 80
4) Provider Reviews Settings .................................................................................................................................................. 81
5) Quality of Care Concerns Confirmed ................................................................................................................................. 82
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by
Notification Type ............................................................................................................................................................... 84
7) Reviews by Geographic Area – Urban and Rural ............................................................................................................... 85
8) Immediate Advocacy Reviews ........................................................................................................................................... 85
Livanta QIO Area #1 – US Virgin Islands .......................................................................................................................................... 86
1) Total # of Reviews.............................................................................................................................................................. 86
2) Top 10 Principal Medical Diagnoses .................................................................................................................................. 87
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
3) Beneficiary Demographics ................................................................................................................................................. 87
4) Provider Reviews Settings .................................................................................................................................................. 88
5) Quality of Care Concerns Confirmed ................................................................................................................................. 89
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by
Notification Type ............................................................................................................................................................... 91
7) Reviews by Geographic Area – Urban and Rural ............................................................................................................... 92
8) Immediate Advocacy Reviews ........................................................................................................................................... 92
Livanta QIO Area #1 – State of Vermont ........................................................................................................................................... 93
1) Total # of Reviews.............................................................................................................................................................. 93
2) Top 10 Principal Medical Diagnoses .................................................................................................................................. 94
3) Beneficiary Demographics ................................................................................................................................................. 95
4) Provider Reviews Settings .................................................................................................................................................. 96
5) Quality of Care Concerns Confirmed ................................................................................................................................. 97
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital Admissions Outcomes by
Notification Type ............................................................................................................................................................... 99
7) Reviews by Geographic Area – Urban and Rural ............................................................................................................. 100
8) Immediate Advocacy Reviews ......................................................................................................................................... 100
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
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INTRODUCTION: Livanta LLC is the Centers for Medicare & Medicaid Services (CMS) designated Beneficiary and Family
Centered Care Quality Improvement Organization (BFCC-QIO) for Area 1, which includes the states of
Connecticut, Massachusetts, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and
Vermont, as well as Puerto Rico and the US Virgin Islands.
The QIO Program, one of the largest federal programs dedicated to improving health quality for Medicare
beneficiaries, is an integral part of the U.S. Department of Health and Human (HHS) Services’ National Quality
Strategy for providing better care and better health at lower cost. By law, the mission of the QIO Program is to
improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries.
CMS identifies the core functions of the QIO Program as:
• Improving quality of care for beneficiaries;
• Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services
and goods that are reasonable and necessary and that are provided in the most appropriate setting;
and
• Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary
complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and
Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law.
BFCC-QIOs improve healthcare services and protect beneficiaries through expeditious statutory review
functions, including complaints and quality of care reviews for people with Medicare. The BFCC-QIO ensures
consistency in the case review process while taking into consideration local factors and local needs for general
quality of care, medical necessity, and readmissions.1
This annual report provides data regarding case reviews that were completed on behalf of Medicare
beneficiaries and their representatives, health care providers, and CMS for the date range of August 1, 2015
through July 31, 2016. Readers will find the overall Area 1 data in the first 12 sections of this report, and state-
specific data in the Appendix section of the report. This report underscores our commitment to transparency by
providing key performance metrics from the second year of Livanta’s work with Medicare beneficiaries.
Livanta understands and respects beneficiaries’ rights and concerns, and we are dedicated to protecting patients
by reviewing appeals and quality complaints in an effective and efficient patient-centered manner. For more
information on Livanta’s performance metrics, please visit our online dashboard.
1“Quality Improvement Organizations.” CMS.gov. Centers for Medicare & Medicaid Services. September 12, 2016. Web. September
29, 2016.
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SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
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LIVANTA QIO AREA #1 – SUMMARY
1) TOTAL # OF REVIEWS
Livanta completed reviews on behalf of Medicare beneficiaries receiving care in Area 1. This table breaks out
the number of reviews by the different types of reviews we conducted.
Review Type # of Reviews Percent of TOTAL
Reviews (%)
Coding Validation (120 - HWDRG)2 8,304 10.82%
Coding Validation (All Other Selection Reasons)2 15 0.02%
Quality of Care Review (101 through 104 - Beneficiary Complaint) 1,105 1.44%
Quality of Care Review (All Other Selection Reasons) 468 0.62%
Utilization (158 - FI/MAC Referral for Readmission Review) 0 0.00%
Utilization (All Other Selection Reasons) 20,419 26.62%
Notice of Non-coverage (105 through 108 - Admission and
Preadmission) 1,192 1.55%
Notice of Non-coverage (118 - BIPA) 13,911 18.13%
Notice of Non-coverage (117 - Grijalva) 23,357 30.45%
Notice of Non-coverage (121 through 124 - Weichardt) 7,819 10.19%
Notice of Non-coverage (111-Request for QIO Concurrence) 78 0.10%
Emergency Medical Treatment & Labor Act (EMTALA) 5 Day 3 46 0.06%
EMTALA 60 Day3 0 0.00%
Total 76,714 100.00%
2 Coding Validations and Utilization Reviews: Livanta reviews medical records to verify that the coding is accurate, that the care provided was
medically necessary, and that the care provided was delivered in the most appropriate setting. Certain hospital claims submitted as part of hospital
billing trigger reviews by Livanta, as the proposed changes to billing codes would allow the hospital to receive more money for the care delivered.
Currently, CMS refers all claims of this type in Area 1 to Livanta for review. We ensure that the care provided accurately matches the provider’s
claim for payment, and that the claim was coded correctly for billing purposes.
3 EMTALA Reviews: Livanta reviews cases that may be in violation of the Emergency Medical Treatment and Labor Act (EMTALA). EMTALA is a
federal law requiring that patients who need stabilization for an emergency medical condition receive that care, regardless of their ability to pay.
CMS refers cases of this kind to Livanta in Area 1 on an as-needed basis. We determine whether the medical screening was adequate, whether an
emergency medical condition existed, and if so, whether the patient was stabilized before a transfer. We also review the quality of care provided.
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
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2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES:
This table provides information regarding the top 10 medical diagnoses for inpatient claims billed during the
annual reporting period for Medicare patients in Area 1.
Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries (%)
1. A419 - SEPSIS, UNSPECIFIED
ORGANISM 83,369 20.86%
2. 0389 - SEPTICEMIA NOS 70,869 17.73%
3. J189 - PNEUMONIA,
UNSPECIFIED ORGANISM 39,369 9.85%
4. 486 - PNEUMONIA,
ORGANISM NOS 34,795 8.70%
5. J441 - CHRONIC
OBSTRUCTIVE PULMONARY
DISEASE W (ACUTE)
EXACERBATION
32,490 8.13%
6. N179 - ACUTE KIDNEY
FAILURE, UNSPECIFIED 30,453 7.62%
7. N390 - URINARY TRACT
INFECTION, SITE NOT
SPECIFIED
27,953 6.99%
8. I214 - NON-ST ELEVATION
(NSTEMI) MYOCARDIAL
INFARCTION
27,374 6.85%
9. 5849 - ACUTE KIDNEY
FAILURE NOS 27,003 6.76%
10. 5990 - URINARY TRACT
INFECTION NOS 26,047 6.52%
Total 399,722 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
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3) PROVIDER REVIEWS SETTINGS:
This table provides information on the count and percent by setting for Health Service Providers (HSPs)
associated with a completed BFCC-QIO review in Area 1.
Setting # of Providers Percent of Providers
(%)
0: Acute Care Unit of an Inpatient Facility 538 15.84%
1: Distinct Psychiatric Facility 28 0.82%
2: Distinct Rehabilitation Facility 44 1.30%
3: Distinct Skilled Nursing Facility 2,182 64.25%
5: Clinic 0 0.00%
6: Distinct Dialysis Center Facility 3 0.09%
7: Dialysis Center Unit of Inpatient Facility 2 0.06%
8: Independent Based RHC 0 0.00%
9: Provider Based RHC 0 0.00%
C: Free Standing Ambulatory Surgery Center 4 0.12%
G: End Stage Renal Disease Unit 6 0.18%
H: Home Health Agency 292 8.60%
N: Critical Access Hospital 31 0.91%
O: Setting Does Not Fit Into Any Other Existing Setting
Code 0 0.00%
Q: Long Term Care Facility 42 1.24%
R: Hospice 209 6.15%
S: Psychiatric Unit of an Inpatient Facility 6 0.18%
T: Rehabilitation Unit of an Inpatient Facility 4 0.12%
U: Swing Bed Hospital Designation for Short-Term, Long-
Term Care, and Rehabilitation Hospitals 2 0.06%
Y: Federally Qualified Health Centers 3 0.09%
Z: Swing Bed Designation for Critical Access Hospitals 0 0.00%
Other 0 0.00%
Total 3,396 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
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4) QUALITY OF CARE CONCERNS CONFIRMED
This table provides the number of confirmed quality of care concerns as identified by Physician Reviewer
Assessment Form (PRAF) category codes within the CMS Case Review Information System (CRIS). These
quality of care concerns are confirmed by Livanta’s independent physician reviewers as care that did not meet
the professionally recognized standards of medical care. Confirmed quality of care concerns are provided
education and referred as appropriate to the CMS designated Quality Innovation Network Quality Improvement
Organization (QIN-QIO) contractors who work with providers to make improvements in patient care.
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of
Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives
(QII)
C01: Apparently did not obtain pertinent history
and/or findings from examination 10 1 10.00% 2
C02: Apparently did not make appropriate
diagnoses and/or assessments 330 39 11.82% 23
C03: Apparently did not establish and/or develop
an appropriate treatment plan for a defined
problem or diagnosis which prompted this
episode of care [excludes laboratory and/or
imaging (see C06 or C09) and procedures (see
C07 or C08) and consultations (see C13 and
C14)
981 79 8.05% 5
C04: Apparently did not carry out an established
plan in a competent and/or timely fashion 306 34 11.11% 16
C05: Apparently did not appropriately assess
and/or act on changes in clinical/other status
results
163 15 9.20% 1
C06: Apparently did not appropriately assess
and/or act on laboratory tests or imaging study
results
39 11 28.21% 10
C07: Apparently did not establish adequate
clinical justification for a procedure which
carries patient risk and was performed
52 13 25.00% 0
C08: Apparently did not perform a procedure
that was indicated (other than laboratory and
imaging, see C09)
41 9 21.95% 1
C09: Apparently did not obtain appropriate
laboratory tests and/or imaging studies 107 12 11.21% 0
C10: Apparently did not develop and initiate
appropriate discharge, follow-up, and/or
rehabilitation plans
196 18 9.18% 11
C11: Apparently did not demonstrate that the 310 23 7.42% 2
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
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Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of
Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives
(QII)
patient was ready for discharge
C12: Apparently did not provide appropriate
personnel and/or resources 2 1 50.00% 0
C13: Apparently did not order appropriate
specialty consultation 84 7 8.33% 3
C14: Apparently specialty consultation process
was not completed in a timely manner 20 3 15.00% 3
C15: Apparently did not effectively coordinate
across disciplines 53 8 15.09% 5
C16: Apparently did not ensure a safe
environment (medication errors, falls, pressure
ulcers, transfusion reactions, nosocomial
infection)
364 40 10.99% 10
C17: Apparently did not order/follow evidence-
based practices 52 7 13.46% 5
C18: Apparently did not provide medical record
documentation that impacts patient care 12 4 33.33% 9
C40: Apparently did not follow up on patient’s
non-compliance 1 0 0.00% 0
C99: Other quality concern not elsewhere
classified 579 84 14.51% 4
Total 3,702 408 11.02% 110
5) DISCHARGE/SERVICE TERMINATION
This table provides information regarding the discharge location of beneficiaries linked to appeals conducted by
Livanta of provider-issued notices of Medicare non-coverage. Data contained in this table represents
discharge/termination of service reviews from August 1, 2015 through April 30, 2016. A shortened timeframe is
necessary to allow for maturity of claims data, which are the source of “Discharge Status” for these cases.
Discharge Status # of Beneficiaries Percent of Beneficiaries
(%)
01: Discharged to home or self care (routine
discharge) 629 21.11%
02: Discharged/transferred to another short-term
general hospital for inpatient care 41 1.38%
03: Discharged/transferred to skilled nursing
facility (SNF) 1,367 45.87%
04: Discharged/transferred to intermediate care
facility (ICF) 32 1.07%
BFCC-QIO 11th
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Discharge Status # of Beneficiaries Percent of Beneficiaries
(%)
05: Discharged/transferred to another type of
institution (including distinct parts) 4 0.13%
06: Discharged/transferred to home under care of
organized home health service organization 617 20.70%
07: Left against medical advice or discontinued
care 10 0.34%
09: Admitted as an inpatient to this hospital 1 0.03%
20: Expired (or did not recover – Christian Science
patient) 36 1.21%
21: Discharged/transferred to court/law
enforcement 3 0.10%
30: Still a patient 6 0.20%
40: Expired at home (Hospice claims only) 0 0.00%
41: Expired in a medical facility (e.g. hospital,
SNF, ICF or free standing Hospice) 0 0.00%
42: Expired – place unknown (Hospice claims
only) 0 0.00%
43: Discharged/transferred to a Federal hospital 2 0.07%
50: Hospice - home 42 1.41%
51: Hospice - medical facility 23 0.77%
61: Discharged/transferred within this institution to
a hospital-based Medicare approved swing bed 2 0.07%
62: Discharged/transferred to an inpatient
rehabilitation facility including distinct part units
of a hospital
118 3.96%
63: Discharged/transferred to a long term care
hospital 32 1.07%
64: Discharged/transferred to a nursing facility
certified under Medicaid but not under Medicare 3 0.10%
65: Discharged/transferred to a psychiatric hospital
or psychiatric distinct part unit of a hospital 9 0.30%
66: Discharged/transferred to a Critical Access
Hospital 0 0.00%
70: Discharged/transferred
to another type of health care institution not
defined elsewhere in code list
3 0.10%
Other 0 0.00%
Total 2,980 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
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6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
This table provides the number of appeal reviews and the percentage of reviews, specifically for each outcome,
in which Livanta’s independent physician reviewer agreed or disagreed with the discharge.
Appeal Review by Notification Type # of Reviews
Physician Reviewer
Disagreed with
Discharge (%)
Physician Reviewer
Agreed with
Discharge (%)
105: Notice of Non-coverage FFS
Preadmission Notice Concurrent Immediate
Review
260 33.46% 66.54%
106: Notice of Non-coverage FFS
Preadmission Notice Non-immediate Review 6 16.67% 83.33%
107: Notice of Non-coverage FFS Admission
Notice Concurrent Immediate Review 893 32.70% 67.30%
108: Notice of Non-coverage FFS Admission
Notice Non-immediate Review 6 33.33% 66.67%
111: Notice of Non-coverage Request for
QIO Concurrence 56 25.00% 75.00%
117: MA Appeal Review (CORF, HHA,
SNF) 19,901 27.50% 72.48%
118: FFS Expedited Appeal (CORF, HHA,
Hospice, SNF) 12,063 17.68% 82.30%
121: Notice of Non-coverage Continued Stay
Notice Immediate Review - Attending
Physician Concurs
4,126 6.69% 93.24%
122: Notice of Non-coverage Continued Stay
Notice Concurrent Non-immediate Review 380 12.89% 87.11%
123: Notice of Non-coverage Continued Stay
Retrospective 765 16.60% 83.40%
124: MA Notice of Non-coverage Continued
Stay Notice Immediate Review - Attending
Physician Concurs
1,892 8.62% 91.33%
Total 40,348 21.35% 78.62%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
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7) EVIDENCE USED IN DECISION-MAKING
The following table describes one or more of the most common types of evidence or standards of care used to
support Livanta’s review coordinators and independent physician reviewer decisions for medical
necessity/utilization review and appeals. Livanta uses evidence-based guidelines and medical literature to
identify standards of care, where such standards exist.
For quality of care reviews, we have provided one to three of the most highly utilized types of
evidence/standards of care to support Livanta’s review coordinator and independent physician reviewer
decisions for the specific list of diagnostic categories provided in this table. A brief statement of the rationale
for selecting the specific evidence or standards of care is also included.
Review Type Diagnostic
Categories
Evidence/ Standards of
Care Used
Rationale for
Evidence/Standard of Care
Selected
Quality of Care
Pneumonia
UpToDate: Treatment of
hospital-acquired,
ventilator-associated, and
healthcare-associated
pneumonia in adults
UpToDate is a web-based
resource that provides multiple
evidence-based standards of
care and clinical decision
support.
Heart Failure UpToDate: Evaluation of
the patient with suspected
heart failure
UpToDate is a web-based
resource that provides multiple
evidence-based standards of
care and clinical decision
support.
Pressure Ulcers UpToDate: Clinical
staging and management
of pressure ulcers
UpToDate is a web-based
resource that provides multiple
evidence-based standards of
care and clinical decision
support.
Acute Myocardial
Infarction
UpToDate: Overview of
the acute management of
ST elevation myocardial
infarction
UpToDate is a web-based
resource that provides multiple
evidence-based standards of
care and clinical decision
support.
Urinary Tract
Infection
UpToDate: Acute
complicated cystitis and
pyelonephritis
UpToDate is a web-based
resource that provides multiple
evidence-based standards of
care and clinical decision
support.
Sepsis UpToDate: Sepsis and the
systemic inflammatory
response syndrome:
Definitions,
epidemiology, and
prognosis
UpToDate is a web-based
resource that provides multiple
evidence-based standards of
care and clinical decision
support.
BFCC-QIO 11th
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Review Type Diagnostic
Categories
Evidence/ Standards of
Care Used
Rationale for
Evidence/Standard of Care
Selected
Quality of Care Adverse Drug Events UpToDate: Drug
prescribing for older
adults
UpToDate is a web-based
resource that provides multiple
evidence-based standards of
care and clinical decision
support.
Falls UpToDate: Falls:
Prevention in nursing care
facilities and the hospital
setting
UpToDate is a web-based
resource that provides multiple
evidence-based standards of
care and clinical decision
support.
Patient Trauma UpToDate: Initial
Management of Trauma in
Adults
UpToDate is a web-based
resource that provides multiple
evidence-based standards of
care and clinical decision.
Surgical
Complications
UpToDate: Surgical
Complications/Procedure
specific
UpToDate is a web-based
resource that provides multiple
evidence-based standards of
care and clinical decision
support.
Review Type Evidence/ Standards
of Care Used Rationale for Evidence/Standard of Care Selected
Medical
Necessity/Utilization
Review
MCG® and Interqual MCG® and InterQual are standard, evidence-based criteria
used to assess when and how individual patients progress
through the continuum of care.
Livanta also applies CMS's Two Midnight Rule, which
states that inpatient admissions are generally appropriate if
the admitting practitioner expected the patient to require a
hospital stay that crossed two midnights and the medical
record supports that reasonable expectation.
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Review Type Evidence/ Standards
of Care Used Rationale for Evidence/Standard of Care Selected
Appeals Medicare Benefit
Policy Manual
According to the Medicare Benefit Policy Manual, Chapter
8, care in a skilled nursing facility (SNF) is covered if four
factors are met.
Physician reviewers apply those four requirements to each
case reviewed. If ANY ONE of those four factors is not met,
a stay in a SNF, even though it might include delivery of
some skilled services, is not covered.
Medicare Managed
Care Guidelines,
Chapter 13
Reconsideration Timing:
“If the QIO upholds a Medicare health plan’s decision to
terminate services in whole or in part, the enrollee may
request, no later than 60 days after notification that the QIO
has upheld the decision, that the QIO reconsider its original
decision.”
CMS Beneficiary
Notices Initiative
(BNI) website
Forms, model letter template language and instructions for
providers.
“The provider must ensure that the beneficiary or
representative signs and dates the NOMNC to demonstrate
that the beneficiary or representative received the notice and
understands that the termination decision can be disputed.”
CMS Publication
100-04, Medicare
Claims Processing
Manual, Chapter 30:
Financial Liability
Protections
Instructions regarding hospital interactions with QIOs:
“Before Medicare can pay for post-hospital extended care
services, it must determine whether the beneficiary had a
prior qualifying hospital stay of at least three consecutive
calendar days.”
The Medicare Quality
Improvement
Organization Manual,
Publication 100-10,
Chapter 7- Denials,
Reconsiderations, &
Appeals.
This includes related instructions for the Quality
Improvement Organization (QIO) processing of Appeals
Local Coverage
Determinations
(LCDs)
These are coverage determinations for specific situations,
and they are published by Medicare Administrative
Contractors for cases within their own jurisdiction.
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Review Type Evidence/ Standards
of Care Used Rationale for Evidence/Standard of Care Selected
Appeals Code of Federal
Regulations
§422.622 Requesting immediate QIO review of the decision
to discharge from the inpatient hospital: “Procedures the
QIO must follow: (1) When the QIO receives the request for
an expedited determination under paragraph (b)(1) of this
section, it must immediately notify the hospital that a request
for an expedited determination has been made. (2) The QIO
determines whether the hospital delivered valid notice
consistent with §405.1205(b)(3). (3) The QIO examines the
medical and other records that pertain to the services in
dispute. (4) The QIO must solicit the views of the
beneficiary (or the beneficiary's representative) who
requested the expedited determination. (5) The QIO must
provide an opportunity for the hospital to explain why the
discharge is appropriate.”
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8) REVIEWS BY GEOGRAPHIC AREA
These tables provide information for Area 1 about the count and percentage by rural vs. urban geographical
locations for Health Service Providers (HSPs) associated with a completed BFCC-QIO review. Table 8A
provides data for Appeals, and Table 8B provides data for Quality of Care reviews.
Table 8A: Appeals Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers Percent of Providers in
Service Area (%)
Appeal Reviews
Urban 2,912 88.92%
Rural 357 10.90%
Unknown 6 0.18%
Total 3,275 100.00%
Table 8B: Quality of Care Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers Percent of Providers in
Service Area (%)
Quality of Care Reviews
Urban 635 92.84%
Rural 45 6.58%
Unknown 4 0.58%
Total 684 100.00%
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9) OUTREACH AND COLLABORATION WITH BENEFICIARIES
Overview
The outreach and communication efforts of Livanta are designed to generate and maintain a regular flow of
information to major stakeholders and to educate customers in the roles and purposes of the BFCC-QIO.
Ensuring relevant parties have access and exposure to this information is vital to quality control, efficient use of
resources, and a positive customer experience, as it increases situational understanding to all parties involved.
The availability of information and education initiatives allows Livanta to clearly establish expectations with
customers and providers and to educate stakeholders on the roles and purposes of each player. Employing
regularly used platforms of communication, Livanta provides pertinent information to stakeholders in an
efficient and effective manner. This document outlines Livanta’s efforts to provide user-friendly access of
information and educational efforts to all major stakeholders in the BFCC-QIO process.
Beneficiaries and Families
To ensure that beneficiaries and their family members have access to the services of the BFCC-QIO, Livanta
provides a toll-free HelpLine at 1-866-815-5440. The HelpLine also maintains a TTY line at 1-866-868-2289
for use by the hearing impaired. In order to remove any potential language or cultural barriers to using the
services of the BFCC-QIO, Livanta retains a translation firm to translate voice conversations in real-time as
well as to translate any written correspondence into the language of choice for the beneficiary. Additionally,
Livanta’s Intake Center is fully bilingual, offering immediate Spanish language support for callers.
In order to better engage more technology oriented beneficiaries, family members of beneficiaries and their
advocates, Livanta continues to develop and promote the use of the Medicare Quality HelpLine smartphone
app. Users may download the app and automatically connect with a nurse who can help begin the process of
filing a quality of care complaint or an appeal. In addition, Livanta continues to develop and promote the Arrow
program on the Livanta BFCC-QIO website. Arrow allows a user to access up to the minute status information
on individual cases while protecting sensitive information.
Successful Engagement
Due to direct feedback from Livanta’s October 2015 outreach site visit to San Juan, Puerto Rico, it was
determined that the establishment of a local area code phone number for Puerto Rico beneficiaries would
provide an efficient and cost effective method to engage beneficiaries who might otherwise have not placed a
call due to the perception of a language barrier. This feedback was the result of an in-depth sensing session with
members of the Puerto Rico senior advocacy community, as well as further meetings with religious leaders and
state and federal government offices, all conducted on-site in Puerto Rico. This local phone number was warmly
received by the stakeholder community in Puerto Rico and has seen consistent growth in usage since its
implementation in December 2015, seeing a total of 483 calls to date. Livanta continues to engage the
beneficiary and stakeholder community in Puerto Rico to educate on the role of the BFCC-QIO Program and to
accommodate local concerns through the partnerships forged during the outreach trip.
Providers
Livanta continues to regularly engage the provider community through webinars, presentations, and
publications to support ongoing provider education. The information presented can be used by all of Livanta’s
provider community to better understand the role of the BFCC-QIO program in the delivery of quality
healthcare. Livanta’s BFCC-QIO content is routinely updated to keep providers informed about program
requirements, CMS updates, news of interest, and frequently asked questions. Allowing both provider and
beneficiary to access to the Arrow program helps facilitate synchronicity of information amongst stakeholders.
In addition to the regular provider communications and web-based electronic platforms, it continues to engage
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provider associations to more efficiently disseminate information in a timely and targeted fashion. This
proactive engagement of the provider community promotes a better understanding of the BFCC-QIO program
and the rapid dissemination of critical programmatic information.
Advocates
Through consistent and targeted outreach, Livanta has engaged directly with advocate groups in every state and
territory in Area 1. Livanta maintains regular contact with area agencies on aging, the State Health Insurance
Assistance Program (SHIP), the Serving the Health Insurance Needs of Everyone (SHINE) offices at the state
and regional level, the state ombudsman programs, Congressional constituent services offices, and ethnic and
cultural advocacy groups. In the past year, Livanta has had on-site collaboration meetings with 47 critical
advocate stakeholders. In order to conduct these meetings, Livanta has invested considerable research time in
order to identify the most effective partner-advocates. Meetings were held on-site in the various states in
territories, including Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Pennsylvania and Puerto
Rico. Livanta also proactively engages the health staff of members of the House of Representatives and the
United States Senate. These meetings provide valuable insight into regionally specific issues facing beneficiary
populations in the home districts. In the past year, Livanta has conducted one on one briefings with 35
Congressional offices in Area 1. With the successful completion of those visits, Livanta has now met with staff
from all of the Area 1 members of Congress. As with advocates in religious, cultural, ethnic and senior groups,
efforts are ongoing to stay in close communication in order to facilitate engagement and education as Livanta
makes innovations to meet the changing needs of Medicare beneficiaries.
Education through Communication
Because of the rapidly changing nature of healthcare, Livanta is committed to providing up-to-date BFCC-QIO
information to the general public, stakeholders, providers and advocates. To educate customers on these
updates, the CMS Twitter feed @BeneProtection is featured live on Livanta’s website. The Livanta BFCC-QIO
website is available for beneficiaries to access in 10 different languages. Each of the languages represented on
the website reflect either a high volume of speakers in Area 1 or a vulnerable population in Area 1. Thanks to
direct feedback obtained during an outreach trip to meet with beneficiary advocates in New Bedford,
Massachusetts, it was determined that Portuguese language support. As such, Portuguese language support was
added to Livanta’s BFCC-QIO webpages. Thanks to the consistent education and outreach, utilization of
Livanta’s BFCC-QIO webpages has resulted in 122,358 unique users. Each user represents an individual
beneficiary, family member or advocate accessing the resources and information on the website.
Other Partners
Livanta maintains a close working relationship with CMS and regularly collaborates with the Contracting
Officer Representatives (CORS) assigned to the Livanta contract. Livanta also works in conjunction with other
Medicare contractors who support the BFCC-QIO, and will often combine resources to sponsor outreach
initiatives for increased efficiency and effectiveness. In addition to joining the Virgin Islands Healthcare
Coalition Workgroup with the Health Services Advisory Group (the QIN-QIO for the US Virgin Islands),
Livanta has collaborated with the Quality Improvement Professional Research Organization and the Quality
Innovation Network Quality Improvement Organization (QIN-QIO) for Puerto Rico to engage the provider
community there.
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10) IMMEDIATE ADVOCACY REVIEWS
Immediate Advocacy is an informal, voluntary process used by Livanta to resolve complaints quickly. This
process begins when the beneficiary or his or her representative contacts Livanta and gives verbal consent to
proceed with the complaint. Once consent is given, Livanta contacts the provider and/or practitioner on behalf
of the Medicare patient. Immediate Advocacy is not appropriate when a patient wants to remain anonymous.
Immediate Advocacy does not take the place of a clinical quality of care review, which includes an assessment
of the patient’s medical records.
# of Beneficiary
Complaints
# of Immediate Advocacy
Reviews
(%) of Total Beneficiary
Complaints Resolved by
Immediate Advocacy
Immediate Advocacy Reviews
1,644
622
37.83%
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11) EXAMPLE/SUCCESS STORY
Quality Success Stories
Example 1:
Livanta received a phone call from a Medicare beneficiary who reported that he was unable to obtain his
diabetic test strips and meter due to his physician’s office not submitting the necessary Medicare forms to the
pharmacy. He further reported that the pharmacy faxed the forms to the physician’s office 3 times to complete
and he also hand delivered the forms to the office.
Following the call, Livanta’s Review Coordinator (RC) contacted the provider and spoke to a staff member in
the Risk Management department. The RC requested that the provider complete the necessary paperwork and
fax the information to the pharmacy. Later that day, the RC followed-up with the provider to ensure the task
was completed. The RC discovered that the paperwork submitted to the pharmacy was still incomplete and
covered only the diabetic meter and not the test strips. The RC requested that the provider submit the missing
information and the task was completed.
The RC notified the beneficiary that all of the paperwork was completed and submitted to the pharmacy, and
the beneficiary went to the pharmacy to pick up his diabetic supplies. The beneficiary later called the RC to
confirm that he had all of his diabetic supplies and to thank her for her assistance.
Example 2:
Livanta received a phone call from a Medicare beneficiary who reported that she was recently discharged from
an acute hospital without home health care. Livanta’s RC contacted the hospital’s Home Health Coordinator to
discuss the beneficiary’s discharge plans. Though it was revealed that home health services were ordered by the
physician at discharge, there was difficulty in the initial set-up due to the beneficiary’s residential location and
the inability to finalize by the time the beneficiary left the hospital.
As a result of Livanta’s Immediate Advocacy assistance, the hospital’s Coordinator called the beneficiary and
the home health agency to complete the discharge instructions. Livanta’s RC called the beneficiary to confirm
that services were set, and the beneficiary reported that her home health visit was scheduled for that day.
12) BENEFICIARY HELPLINE STATISTICS
This table provides Livanta’s Area 1 beneficiary HelpLine statistics for the period from August 1, 2015 through
July 31, 2016.
Beneficiary Helpline Report Total Per Category
Total Number of Calls Received 135,780
Total Number of Calls Answered 109,911
Total Number of Abandoned Calls 3,338
Average Length of Call Wait Times 0:13 Seconds
Number of Calls Transferred by 1-800-
Medicare 1,476
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CONCLUSION: Livanta’s quality improvement efforts result in the protection of beneficiaries by ensuring that the quality of
health care they receive meets professionally recognized standards of care. During the course of the second year
of their contract, Livanta received 135,780 calls from beneficiaries, collaborated with 3,396 providers and met
personally with 82 critical stakeholders. All of these interactions are important to the Medicare program. The
QIOs support CMS’s initiative of ensuring that all Medicare beneficiaries receive good quality care every time
by ensuring that the medical care is paid for by Medicare when it is medically necessary and the care that is
provided meets the standards of care set by the medical community. The QIOs support Medicare beneficiaries
and providers through the care continuum. During these interactions, Livanta was able to provide information,
education, and determinations that support the Medicare program. The significance of these interactions cannot
be understated.
Through a review of beneficiary complaints and appeals, Livanta ensures that the perspective and unique needs
of beneficiaries and their representatives are heard, understood and considered, both in making decisions about
current care, and in helping health care facilities provide better care for all beneficiaries in the future. Through
the Immediate Advocacy segment of Livanta’s role as BFCC-QIO, rapid resolution to problems with concurrent
care is possible. For example, Immediate Advocacy can resolve logistical issues with care, such as access to
expected supplies or equipment. Within Livanta’s Quality of Care Program, when a quality of care concern is
confirmed, educational feedback is delivered to the provider regarding how care can be improved in future
cases. Likewise, where a systemic issue is identified, cases are referred to the state's local QIN-QIO to provide
local technical assistance to the health care provider organization to address the underlying issues that may have
led to the failure in care.
Through the handling of appeals, EMTALA cases, and utilization reviews, Livanta also protects beneficiary
rights and the integrity of the Medicare Trust Fund by ensuring that Medicare pays for only health care services
and items that are reasonable and medically necessary, and that these services are provided in the most
appropriate setting. This also impacts the quality of care delivered. Any time a health care provider delivers care
that is invasive but not medically necessary, there will be the risk of unnecessary harm to the patient.
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APPENDIX
LIVANTA QIO AREA #1 – STATE OF CONNECTICUT
1) TOTAL # OF REVIEWS
Review Type # of Reviews
Percent of
TOTAL
Reviews (%)
Coding Validation (120 - HWDRG) 322 8.24%
Coding Validation (All Other Selection Reasons) 0 0.00%
Quality of Care Review (101 through 104 -Beneficiary Complaint) 70 1.79%
Quality of Care Review (All Other Selection Reasons) 31 0.79%
Utilization (158 - FI/MAC Referral for Readmission Review) 0 0.00%
Utilization (All Other Selection Reasons) 877 22.43%
Notice of Non-coverage (105 through 108 - Admission and Preadmission) 28 0.72%
Notice of Non-coverage (118 - BIPA) 1,133 28.98%
Notice of Non-coverage (117 - Grijalva) 1,111 28.41%
Notice of Non-coverage (121 through 124 -Weichardt) 338 8.64%
Notice of Non-coverage (111-Request for QIO Concurrence) 0 0.00%
EMTALA 5 Day 0 0.00%
EMTALA 60 Day 0 0.00%
Total 3,910 100.00%
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2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries
(%)
1. 0389 - SEPTICEMIA NOS 6,932 20.97%
2. A419 - SEPSIS, UNSPECIFIED
ORGANISM 6,272 18.97%
3. 486 - PNEUMONIA, ORGANISM NOS 3,148 9.52%
4. 5849 - ACUTE KIDNEY FAILURE NOS 2,878 8.71%
5. 5990 - URIN TRACT INFECTION NOS 2,663 8.06%
6. N179 - ACUTE KIDNEY FAILURE,
UNSPECIFIED 2,541 7.69%
7. J189 - PNEUMONIA, UNSPECIFIED
ORGANISM 2,393 7.24%
8. 42833 - AC ON CHR DIAST HRT FAIL 2,160 6.53%
9. 42731 - ATRIAL FIBRILLATION 2,061 6.23%
10. I5033 - ACUTE ON CHRONIC
DIASTOLIC (CONGESTIVE) HEART
FAILURE
2,010 6.08%
Total 33,058 100.00%
3) BENEFICIARY DEMOGRAPHICS
Demographics # of Beneficiaries Percent of Beneficiaries
(%)
Sex/Gender
Female 1,685 59.16%
Male 1,146 40.24%
Unknown 17 0.60%
Total 2,848 100.00%
Race
Asian 9 0.32%
Black 202 7.09%
Hispanic 29 1.02%
North American Native 2 0.07%
Other 28 0.98%
Unknown 42 1.47%
White 2,536 89.04%
Total 2,848 100.00%
Age
Under 65 325 11.41%
65-70 334 11.73%
71-80 735 25.81%
81-90 1,042 36.59%
91+ 412 14.47%
Total 2,848 100.00%
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4) PROVIDER REVIEWS SETTINGS
Setting # of Providers Percent of
Providers (%)
0: Acute Care Unit of an Inpatient Facility 30 11.03%
1: Distinct Psychiatric Facility 1 0.37%
2: Distinct Rehabilitation Facility 1 0.37%
3: Distinct Skilled Nursing Facility 194 71.32%
5: Clinic 0 0.00%
6: Distinct Dialysis Center Facility 0 0.00%
7: Dialysis Center Unit of Inpatient Facility 0 0.00%
8: Independent Based RHC 0 0.00%
9: Provider Based RHC 0 0.00%
C: Free Standing Ambulatory Surgery Center 0 0.00%
G: End Stage Renal Disease Unit 0 0.00%
H: Home Health Agency 31 11.40%
N: Critical Access Hospital 0 0.00%
O: Setting Does Not Fit Into Any Other Existing Setting Code 0 0.00%
Q: Long Term Care Facility 2 0.74%
R: Hospice 12 4.41%
S: Psychiatric Unit of an Inpatient Facility 0 0.00%
T: Rehabilitation Unit of an Inpatient Facility 0 0.00%
U: Swing Bed Hospital Designation for Short-Term, Long-Term Care,
and Rehabilitation Hospitals 0 0.00%
Y: Federally Qualified Health Centers 1 0.37%
Z: Swing Bed Designation for Critical Access Hospitals 0 0.00%
Other 0 0.00%
Total 272 100.00%
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5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C01: Apparently did not obtain pertinent
history and/or findings from examination 0 0 0.00% 2
C02: Apparently did not make appropriate
diagnoses and/or assessments 23 1 4.35% 0
C03: Apparently did not establish and/or
develop an appropriate treatment plan for a
defined problem or diagnosis which
prompted this episode of care [excludes
laboratory and/or imaging (see C06 or C09)
and procedures (see C07 or C08) and
consultations (see C13 and C14)
57 7 12.28% 1
C04: Apparently did not carry out an
established plan in a competent and/or
timely fashion
21 3 14.29%
3
C05: Apparently did not appropriately
assess and/or act on changes in
clinical/other status results
6 0 0.00% 0
C06: Apparently did not appropriately
assess and/or act on laboratory tests or
imaging study results
1 0 0.00% 0
C07: Apparently did not establish adequate
clinical justification for a procedure which
carries patient risk and was performed
3 0 0.00% 0
C08: Apparently did not perform a
procedure that was indicated (other than lab
and imaging, see C09)
3 0 0.00% 0
C09: Apparently did not obtain appropriate
laboratory tests and/or imaging studies 9 0 0.00% 0
C10: Apparently did not develop and
initiate appropriate discharge, follow-up,
and/or rehabilitation plans
12 1 8.33% 1
C11: Apparently did not demonstrate that
the patient was ready for discharge 27 1 3.70% 0
C12: Apparently did not provide
appropriate personnel and/or resources 0 0 0.00% 0
C13: Apparently did not order appropriate
specialty consultation 3 0 0.00% 0
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Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C14: Apparently specialty consultation
process was not completed in a timely
manner
1 0 0.00% 0
C15: Apparently did not effectively
coordinate across disciplines 4 2 50.00% 0
C16: Apparently did not ensure a safe
environment (medication errors, falls,
pressure ulcers, transfusion reactions,
nosocomial infection)
25 3 12.00% 1
C17: Apparently did not order/follow
evidence-based practices 5 2 40.00% 0
C18: Apparently did not provide medical
record documentation that impacts patient
care
1 0 0.00% 1
C40: Apparently did not follow up on
patient’s non-compliance 0 0 0.00% 0
C99: Other quality concern not elsewhere
classified 41 8 19.51% 1
Total 242 28 11.57% 10
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6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Review by Notification Type # of Reviews (%) of Total
105: Notice of Non-coverage FFS Preadmission Notice Concurrent
Immediate Review 5 0.21%
106: Notice of Non-coverage FFS Preadmission Notice Non-immediate
Review 2 0.08%
107: Notice of Non-coverage FFS Admission Notice Concurrent
Immediate Review 19 0.80%
108: Notice of Non-coverage FFS Admission Notice Non-immediate
Review 2 0.08%
111: Notice of Non-coverage Request for QIO Concurrence 0 0.00%
117: MA Appeal Review (CORF, HHA, SNF) 1,001 42.20%
118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 1,019 42.96%
121: Notice of Non-coverage Continued Stay Notice Immediate Review -
Attending Physician Concurs 206 8.68%
122: Notice of Non-coverage Continued Stay Notice Concurrent Non-
immediate Review 12 0.51%
123: Notice of Non-coverage Continued Stay Retrospective 44 1.85%
124: MA Notice of Non-coverage Continued Stay Notice Immediate
Review - Attending Physician Concurs 62 2.61%
Total 2,372 100.00%
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7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeals Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Appeal Reviews
Urban 256 95.88% 88.92%
Rural 9 3.37% 10.90%
Unknown 2 0.75% 0.18%
Total 267 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Quality of Care Reviews
Urban 39 95.12% 92.84%
Rural 1 2.44% 6.58%
Unknown 1 2.44% 0.58%
Total 41 100.00% 100.00%
8) IMMEDIATE ADVOCACY REVIEWS
# of Beneficiary
Complaints # of Immediate Advocacy Reviews
(%) of Total Beneficiary
Complaints Resolved by
Immediate Advocacy
Immediate Advocacy Reviews
88
21
23.86%
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LIVANTA QIO AREA #1 – STATE OF MASSACHUSETTS
1) TOTAL # OF REVIEWS
Review Type # of Reviews
Percent of
TOTAL
Reviews (%)
Coding Validation (120 - HWDRG) 520 10.44%
Coding Validation (All Other Selection Reasons) 0 0.00%
Quality of Care Review (101 through 104 -Beneficiary Complaint) 123 2.47%
Quality of Care Review (All Other Selection Reasons) 60 1.20%
Utilization (158 - FI/MAC Referral for Readmission Review) 0 0.00%
Utilization (All Other Selection Reasons) 1,456 29.22%
Notice of Non-coverage (105 through 108 - Admission and Preadmission) 88 1.77%
Notice of Non-coverage (118 - BIPA) 1,414 28.38%
Notice of Non-coverage (117 - Grijalva) 853 17.12%
Notice of Non-coverage (121 through 124 -Weichardt) 457 9.17%
Notice of Non-coverage (111-Request for QIO Concurrence) 7 0.14%
EMTALA 5 Day 5 0.10%
EMTALA 60 Day 0 0.00%
Total 4,983 100.00%
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2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries
(%)
1. 0389 - SEPTICEMIA NOS 12,013 18.33%
2. A419 - SEPSIS, UNSPECIFIED
ORGANISM 11,352 17.32%
3. 486 - PNEUMONIA, ORGANISM NOS 7,199 10.99%
4. J189 - PNEUMONIA, UNSPECIFIED
ORGANISM 5,915 9.03%
5. 5849 - ACUTE KIDNEY FAILURE NOS 5,302 8.09%
6. 5990 - URIN TRACT INFECTION NOS 5,117 7.81%
7. J441 - CHRONIC OBSTRUCTIVE
PULMONARY DISEASE W (ACUTE)
EXACERBATION
4,883 7.45%
8. 71536 - LOC OSTEOARTH NOS-L/LEG 4,750 7.25%
9. 42833 - AC ON CHR DIAST HRT FAIL 4,550 6.94%
10. N179 - ACUTE KIDNEY FAILURE,
UNSPECIFIED 4,446 6.78%
Total 65,527 100.00%
3) BENEFICIARY DEMOGRAPHICS
Demographics # of Beneficiaries Percent of Beneficiaries
(%)
Sex/Gender
Female 2,295 60.55%
Male 1,468 38.73%
Unknown 27 0.71%
Total 3,790 100.00%
Race
Asian 33 0.87%
Black 144 3.80%
Hispanic 38 1.00%
North American Native 2 0.05%
Other 40 1.06%
Unknown 50 1.32%
White 3,483 91.90%
Total 3,790 100.00%
Age
Under 65 563 14.85%
65-70 445 11.74%
71-80 898 23.69%
81-90 1,328 35.04%
91+ 556 14.67%
Total 3,790 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – M a s s a c h u s e t t s 28 | P a g e
4) PROVIDER REVIEWS SETTINGS
Setting # of Providers Percent of
Providers (%)
0: Acute Care Unit of an Inpatient Facility 59 12.14%
1: Distinct Psychiatric Facility 6 1.23%
2: Distinct Rehabilitation Facility 6 1.23%
3: Distinct Skilled Nursing Facility 324 66.67%
5: Clinic 0 0.00%
6: Distinct Dialysis Center Facility 0 0.00%
7: Dialysis Center Unit of Inpatient Facility 0 0.00%
8: Independent Based RHC 0 0.00%
9: Provider Based RHC 0 0.00%
C: Free Standing Ambulatory Surgery Center 1 0.21%
G: End Stage Renal Disease Unit 0 0.00%
H: Home Health Agency 40 8.23%
N: Critical Access Hospital 2 0.41%
O: Setting Does Not Fit Into Any Other Existing Setting Code 0 0.00%
Q: Long Term Care Facility 12 2.47%
R: Hospice 34 7.00%
S: Psychiatric Unit of an Inpatient Facility 2 0.41%
T: Rehabilitation Unit of an Inpatient Facility 0 0.00%
U: Swing Bed Hospital Designation for Short-Term, Long-Term Care,
and Rehabilitation Hospitals 0 0.00%
Y: Federally Qualified Health Centers 0 0.00%
Z: Swing Bed Designation for Critical Access Hospitals 0 0.00%
Other 0 0.00%
Total 486 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – M a s s a c h u s e t t s 29 | P a g e
5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C01: Apparently did not obtain pertinent
history and/or findings from examination 1 0 0.00% 0
C02: Apparently did not make appropriate
diagnoses and/or assessments 40 6 15.00% 1
C03: Apparently did not establish and/or
develop an appropriate treatment plan for a
defined problem or diagnosis which
prompted this episode of care [excludes
laboratory and/or imaging (see C06 or C09)
and procedures (see C07 or C08) and
consultations (see C13 and C14)
141 11 7.80% 0
C04: Apparently did not carry out an
established plan in a competent and/or
timely fashion
26 3 11.54% 2
C05: Apparently did not appropriately
assess and/or act on changes in
clinical/other status results
13 0 0.00% 5
C06: Apparently did not appropriately
assess and/or act on laboratory tests or
imaging study results
4 0 0.00% 0
C07: Apparently did not establish adequate
clinical justification for a procedure which
carries patient risk and was performed
5 0 0.00% 0
C08: Apparently did not perform a
procedure that was indicated (other than lab
and imaging, see C09)
2 0 0.00% 0
C09: Apparently did not obtain appropriate
laboratory tests and/or imaging studies 15 5 33.33% 0
C10: Apparently did not develop and
initiate appropriate discharge, follow-up,
and/or rehabilitation plans
21 0 0.00% 0
C11: Apparently did not demonstrate that
the patient was ready for discharge 21 2 9.52% 0
C12: Apparently did not provide
appropriate personnel and/or resources 0 0 0.00% 0
C13: Apparently did not order appropriate
specialty consultation 8 0 0.00% 0
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – M a s s a c h u s e t t s 30 | P a g e
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C14: Apparently specialty consultation
process was not completed in a timely
manner
0 0 0.00% 0
C15: Apparently did not effectively
coordinate across disciplines 5 1 20.00% 0
C16: Apparently did not ensure a safe
environment (medication errors, falls,
pressure ulcers, transfusion reactions,
nosocomial infection)
42 6 14.29% 4
C17: Apparently did not order/follow
evidence-based practices 2 1 50.00% 1
C18: Apparently did not provide medical
record documentation that impacts patient
care
0 0 0.00% 2
C40: Apparently did not follow up on
patient’s non-compliance 1 0 0.00% 0
C99: Other quality concern not elsewhere
classified 65 7 10.77% 0
Total 412 42 10.19% 15
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – M a s s a c h u s e t t s 31 | P a g e
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Review by Notification Type # of Reviews (%) of Total
105: Notice of Non-coverage FFS Preadmission Notice Concurrent
Immediate Review 25 1.00%
106: Notice of Non-coverage FFS Preadmission Notice Non-immediate
Review 0 0.00%
107: Notice of Non-coverage FFS Admission Notice Concurrent
Immediate Review 60 2.41%
108: Notice of Non-coverage FFS Admission Notice Non-immediate
Review 1 0.04%
111: Notice of Non-coverage Request for QIO Concurrence 7 0.28%
117: MA Appeal Review (CORF, HHA, SNF) 689 27.63%
118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 1,284 51.48%
121: Notice of Non-coverage Continued Stay Notice Immediate Review -
Attending Physician Concurs 261 10.47%
122: Notice of Non-coverage Continued Stay Notice Concurrent Non-
immediate Review 26 1.04%
123: Notice of Non-coverage Continued Stay Retrospective 61 2.45%
124: MA Notice of Non-coverage Continued Stay Notice Immediate
Review - Attending Physician Concurs 80 3.21%
Total 2,494 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – M a s s a c h u s e t t s 32 | P a g e
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeals Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Appeal Reviews
Urban 461 98.50% 88.92%
Rural 7 1.50% 10.90%
Unknown 0 0.00% 0.18%
Total 468 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Quality of Care Reviews
Urban 81 100.00% 92.84%
Rural 0 0.00% 6.58%
Unknown 0 0.00% 0.58%
Total 81 100.00% 100.00%
8) IMMEDIATE ADVOCACY REVIEWS
# of Beneficiary
Complaints # of Immediate Advocacy Reviews
(%) of Total Beneficiary
Complaints Resolved by
Immediate Advocacy
Immediate Advocacy Reviews
168
51
30.36%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
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LIVANTA QIO AREA #1 – STATE OF MAINE
1) TOTAL # OF REVIEWS
Review Type # of Reviews Percent of TOTAL
Reviews (%)
Coding Validation (120 - HWDRG) 126 10.56%
Coding Validation (All Other Selection Reasons) 0 0.00%
Quality of Care Review (101 through 104 -Beneficiary Complaint) 17 1.42%
Quality of Care Review (All Other Selection Reasons) 5 0.42%
Utilization (158 - FI/MAC Referral for Readmission Review) 0 0.00%
Utilization (All Other Selection Reasons) 457 38.31%
Notice of Non-coverage (105 through 108 - Admission and
Preadmission) 51 4.27%
Notice of Non-coverage (118 - BIPA) 144 12.07%
Notice of Non-coverage (117 - Grijalva) 238 19.95%
Notice of Non-coverage (121 through 124 -Weichardt) 154 12.91%
Notice of Non-coverage (111-Request for QIO Concurrence) 1 0.08%
EMTALA 5 Day 0 0.00%
EMTALA 60 Day 0 0.00%
Total 1,193 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – M a i n e 34 | P a g e
2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries
(%)
1. A419 - SEPSIS, UNSPECIFIED
ORGANISM 1,977 20.14%
2. J189 - PNEUMONIA, UNSPECIFIED
ORGANISM 1,432 14.59%
3. I214 - NON-ST ELEVATION (NSTEMI)
MYOCARDIAL INFARCTION 1,212 12.35%
4. J441 - CHRONIC OBSTRUCTIVE
PULMONARY DISEASE W (ACUTE)
EXACERBATION
1,030 10.49%
5. 0389 - SEPTICEMIA NOS 784 7.99%
6. I5033 - ACUTE ON CHRONIC
DIASTOLIC (CONGESTIVE) HEART
FAILURE
775 7.90%
7. N390 - URINARY TRACT INFECTION,
SITE NOT SPECIFIED 674 6.87%
8. V5789 - REHABILITATION PROC NEC 668 6.81%
9. N179 - ACUTE KIDNEY FAILURE,
UNSPECIFIED 637 6.49%
10. 486 - PNEUMONIA, ORGANISM NOS 627 6.39%
Total 9,816 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – M a i n e 35 | P a g e
3) BENEFICIARY DEMOGRAPHICS
Demographics # of Beneficiaries Percent of Beneficiaries
(%)
Sex/Gender
Female 436 55.68%
Male 337 43.04%
Unknown 10 1.28%
Total 783 100.00%
Race
Asian 1 0.13%
Black 4 0.51%
Hispanic 1 0.13%
North American Native 4 0.51%
Other 2 0.26%
Unknown 13 1.66%
White 758 96.81%
Total 783 100.00%
Age
Under 65 139 17.75%
65-70 95 12.13%
71-80 206 26.31%
81-90 255 32.57%
91+ 88 11.24%
Total 783 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – M a i n e 36 | P a g e
4) PROVIDER REVIEWS SETTINGS
Setting # of Providers Percent of
Providers (%)
0: Acute Care Unit of an Inpatient Facility 18 17.31%
1: Distinct Psychiatric Facility 4 3.85%
2: Distinct Rehabilitation Facility 0 0.00%
3: Distinct Skilled Nursing Facility 65 62.50%
5: Clinic 0 0.00%
6: Distinct Dialysis Center Facility 0 0.00%
7: Dialysis Center Unit of Inpatient Facility 0 0.00%
8: Independent Based RHC 0 0.00%
9: Provider Based RHC 0 0.00%
C: Free Standing Ambulatory Surgery Center 0 0.00%
G: End Stage Renal Disease Unit 0 0.00%
H: Home Health Agency 3 2.88%
N: Critical Access Hospital 10 9.62%
O: Setting Does Not Fit Into Any Other Existing Setting Code 0 0.00%
Q: Long Term Care Facility 0 0.00%
R: Hospice 4 3.85%
S: Psychiatric Unit of an Inpatient Facility 0 0.00%
T: Rehabilitation Unit of an Inpatient Facility 0 0.00%
U: Swing Bed Hospital Designation for Short-Term, Long-Term Care,
and Rehabilitation Hospitals 0 0.00%
Y: Federally Qualified Health Centers 0 0.00%
Z: Swing Bed Designation for Critical Access Hospitals 0 0.00%
Other 0 0.00%
Total 104 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – M a i n e 37 | P a g e
5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C01: Apparently did not obtain pertinent
history and/or findings from examination 0 0 0.00% 0
C02: Apparently did not make appropriate
diagnoses and/or assessments 2 1 50.00% 0
C03: Apparently did not establish and/or
develop an appropriate treatment plan for a
defined problem or diagnosis which
prompted this episode of care [excludes
laboratory and/or imaging (see C06 or C09)
and procedures (see C07 or C08) and
consultations (see C13 and C14)
19 1 5.26% 0
C04: Apparently did not carry out an
established plan in a competent and/or
timely fashion
4 0 0.00% 0
C05: Apparently did not appropriately
assess and/or act on changes in
clinical/other status results
4 1 25.00% 0
C06: Apparently did not appropriately
assess and/or act on laboratory tests or
imaging study results
1 0 0.00% 0
C07: Apparently did not establish adequate
clinical justification for a procedure which
carries patient risk and was performed
1 0 0.00% 0
C08: Apparently did not perform a
procedure that was indicated (other than lab
and imaging, see C09)
0 0 0.00% 0
C09: Apparently did not obtain appropriate
laboratory tests and/or imaging studies 1 0 0.00% 0
C10: Apparently did not develop and
initiate appropriate discharge, follow-up,
and/or rehabilitation plans
5 0 0.00% 0
C11: Apparently did not demonstrate that
the patient was ready for discharge 5 0 0.00% 0
C12: Apparently did not provide
appropriate personnel and/or resources 0 0 0.00% 0
C13: Apparently did not order appropriate
specialty consultation 3 1 33.33% 0
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – M a i n e 38 | P a g e
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C14: Apparently specialty consultation
process was not completed in a timely
manner
0 0 0.00% 1
C15: Apparently did not effectively
coordinate across disciplines 0 0 0.00% 0
C16: Apparently did not ensure a safe
environment (medication errors, falls,
pressure ulcers, transfusion reactions,
nosocomial infection)
6 1 16.67% 1
C17: Apparently did not order/follow
evidence-based practices 1 0 0.00% 0
C18: Apparently did not provide medical
record documentation that impacts patient
care
0 0 0.00% 0
C40: Apparently did not follow up on
patient’s non-compliance 0 0 0.00% 0
C99: Other quality concern not elsewhere
classified 5 2 40.00% 1
Total 57 7 12.28% 3
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – M a i n e 39 | P a g e
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Review by Notification Type # of Reviews (%) of Total
105: Notice of Non-coverage FFS Preadmission Notice Concurrent
Immediate Review 20 3.61%
106: Notice of Non-coverage FFS Preadmission Notice Non-immediate
Review 0 0.00%
107: Notice of Non-coverage FFS Admission Notice Concurrent
Immediate Review 30 5.42%
108: Notice of Non-coverage FFS Admission Notice Non-immediate
Review 0 0.00%
111: Notice of Non-coverage Request for QIO Concurrence 1 0.18%
117: MA Appeal Review (CORF, HHA, SNF) 217 39.17%
118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 134 24.19%
121: Notice of Non-coverage Continued Stay Notice Immediate Review -
Attending Physician Concurs 93 16.79%
122: Notice of Non-coverage Continued Stay Notice Concurrent Non-
immediate Review 12 2.17%
123: Notice of Non-coverage Continued Stay Retrospective 28 5.05%
124: MA Notice of Non-coverage Continued Stay Notice Immediate
Review - Attending Physician Concurs 19 3.43%
Total 554 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – M a i n e 40 | P a g e
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeals Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Appeal Reviews
Urban 53 53.54% 88.92%
Rural 45 45.45% 10.90%
Unknown 1 1.01% 0.18%
Total 99 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Quality of Care Reviews
Urban 11 64.71% 92.84%
Rural 5 29.41% 6.58%
Unknown 1 5.88% 0.58%
Total 17 100.00% 100.00%
8) IMMEDIATE ADVOCACY REVIEWS
# of Beneficiary
Complaints # of Immediate Advocacy Reviews
(%) of Total Beneficiary
Complaints Resolved by
Immediate Advocacy
Immediate Advocacy Reviews
23
5
21.74%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – N e w H a m p s h i r e 41 | P a g e
LIVANTA QIO AREA #1 – STATE OF NEW HAMPSHIRE
9) TOTAL # OF REVIEWS
Review Type # of Reviews
Percent of
TOTAL
Reviews (%)
Coding Validation (120 - HWDRG) 237 21.31%
Coding Validation (All Other Selection Reasons) 0 0.00%
Quality of Care Review (101 through 104 -Beneficiary Complaint) 13 1.17%
Quality of Care Review (All Other Selection Reasons) 7 0.63%
Utilization (158 - FI/MAC Referral for Readmission Review) 0 0.00%
Utilization (All Other Selection Reasons) 475 42.72%
Notice of Non-coverage (105 through 108 - Admission and Preadmission) 44 3.96%
Notice of Non-coverage (118 - BIPA) 163 14.66%
Notice of Non-coverage (117 - Grijalva) 79 7.10%
Notice of Non-coverage (121 through 124 -Weichardt) 91 8.81%
Notice of Non-coverage (111-Request for QIO Concurrence) 2 0.18%
EMTALA 5 Day 1 0.09%
EMTALA 60 Day 0 0.00%
Total 1,112 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – N e w H a m p s h i r e 42 | P a g e
10) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries
(%)
1. A419 - SEPSIS, UNSPECIFIED
ORGANISM 2,083 15.59%
2. 0389 - SEPTICEMIA NOS 1,949 14.59%
3. 486 - PNEUMONIA, ORGANISM NOS 1,360 10.18%
4. J189 - PNEUMONIA, UNSPECIFIED
ORGANISM 1,360 10.18%
5. V5789 - REHABILITATION PROC NEC 1,336 10.00%
6. J441 - CHRONIC OBSTRUCTIVE
PULMONARY DISEASE W (ACUTE)
EXACERBATION
1,158 8.67%
7. 71536 - LOC OSTEOARTH NOS-L/LEG 1,137 8.51%
8. 41071 - SUBENDO INFARCT, INITIAL 1,033 7.73%
9. 49121 - OBS CHR BRONC W(AC) EXAC 992 7.42%
10. I214 - NON-ST ELEVATION (NSTEMI)
MYOCARDIAL INFARCTION 955 7.15%
Total 13,363 100.00%
11) BENEFICIARY DEMOGRAPHICS
Demographics # of Beneficiaries Percent of Beneficiaries
(%)
Sex/Gender
Female 425 58.06%
Male 305 41.67%
Unknown 2 0.27%
Total 732 100.00%
Race
Asian 5 0.68%
Black 4 0.55%
Hispanic 1 0.14%
North American Native 2 0.27%
Other 6 0.82%
Unknown 11 1.50%
White 703 96.04%
Total 732 100.00%
Age
Under 65 123 16.80%
65-70 108 14.75%
71-80 210 28.69%
81-90 203 27.73%
91+ 88 12.02%
Total 732 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – N e w H a m p s h i r e 43 | P a g e
12) PROVIDER REVIEWS SETTINGS
Setting # of Providers Percent of
Providers (%)
0: Acute Care Unit of an Inpatient Facility 13 16.25%
1: Distinct Psychiatric Facility 1 1.25%
2: Distinct Rehabilitation Facility 2 2.50%
3: Distinct Skilled Nursing Facility 44 55.00%
5: Clinic 0 0.00%
6: Distinct Dialysis Center Facility 0 0.00%
7: Dialysis Center Unit of Inpatient Facility 0 0.00%
8: Independent Based RHC 0 0.00%
9: Provider Based RHC 0 0.00%
C: Free Standing Ambulatory Surgery Center 0 0.00%
G: End Stage Renal Disease Unit 1 1.25%
H: Home Health Agency 10 12.50%
N: Critical Access Hospital 5 6.25%
O: Setting Does Not Fit Into Any Other Existing Setting Code 0 0.00%
Q: Long Term Care Facility 0 0.00%
R: Hospice 4 5.00%
S: Psychiatric Unit of an Inpatient Facility 0 0.00%
T: Rehabilitation Unit of an Inpatient Facility 0 0.00%
U: Swing Bed Hospital Designation for Short-Term, Long-Term Care,
and Rehabilitation Hospitals 0 0.00%
Y: Federally Qualified Health Centers 0 0.00%
Z: Swing Bed Designation for Critical Access Hospitals 0 0.00%
Other 0 0.00%
Total 80 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – N e w H a m p s h i r e 44 | P a g e
13) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C01: Apparently did not obtain pertinent
history and/or findings from examination 0 0 0.00% 0
C02: Apparently did not make appropriate
diagnoses and/or assessments 4 0 0.00% 0
C03: Apparently did not establish and/or
develop an appropriate treatment plan for a
defined problem or diagnosis which
prompted this episode of care [excludes
laboratory and/or imaging (see C06 or C09)
and procedures (see C07 or C08) and
consultations (see C13 and C14)
15 2 13.33% 0
C04: Apparently did not carry out an
established plan in a competent and/or
timely fashion
4 0 0.00% 0
C05: Apparently did not appropriately
assess and/or act on changes in
clinical/other status results
0 0 0.00% 1
C06: Apparently did not appropriately
assess and/or act on laboratory tests or
imaging study results
0 0 0.00% 0
C07: Apparently did not establish adequate
clinical justification for a procedure which
carries patient risk and was performed
1 0 0.00% 0
C08: Apparently did not perform a
procedure that was indicated (other than lab
and imaging, see C09)
0 0 0.00% 0
C09: Apparently did not obtain appropriate
laboratory tests and/or imaging studies 2 0 0.00% 0
C10: Apparently did not develop and
initiate appropriate discharge, follow-up,
and/or rehabilitation plans
1 0 0.00% 1
C11: Apparently did not demonstrate that
the patient was ready for discharge 5 1 20.00% 0
C12: Apparently did not provide
appropriate personnel and/or resources 0 0 0.00% 0
C13: Apparently did not order appropriate
specialty consultation 0 0 0.00% 0
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – N e w H a m p s h i r e 45 | P a g e
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C14: Apparently specialty consultation
process was not completed in a timely
manner
1 0 0.00% 0
C15: Apparently did not effectively
coordinate across disciplines 0 0 0.00% 0
C16: Apparently did not ensure a safe
environment (medication errors, falls,
pressure ulcers, transfusion reactions,
nosocomial infection)
6 1 16.67% 0
C17: Apparently did not order/follow
evidence-based practices 1 0 0.00% 0
C18: Apparently did not provide medical
record documentation that impacts patient
care
0 0 0.00% 0
C40: Apparently did not follow up on
patient’s non-compliance 0 0 0.00% 0
C99: Other quality concern not elsewhere
classified 7 1 14.29% 0
Total 47 5 10.64% 2
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – N e w H a m p s h i r e 46 | P a g e
14) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Review by Notification Type # of Reviews (%) of Total
105: Notice of Non-coverage FFS Preadmission Notice Concurrent
Immediate Review 28 8.12%
106: Notice of Non-coverage FFS Preadmission Notice Non-immediate
Review 0 0.00%
107: Notice of Non-coverage FFS Admission Notice Concurrent
Immediate Review 14 4.06%
108: Notice of Non-coverage FFS Admission Notice Non-immediate
Review 1 0.29%
111: Notice of Non-coverage Request for QIO Concurrence 2 0.58%
117: MA Appeal Review (CORF, HHA, SNF) 67 19.42%
118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 142 41.16%
121: Notice of Non-coverage Continued Stay Notice Immediate Review -
Attending Physician Concurs 64 18.55%
122: Notice of Non-coverage Continued Stay Notice Concurrent Non-
immediate Review 9 2.61%
123: Notice of Non-coverage Continued Stay Retrospective 12 3.48%
124: MA Notice of Non-coverage Continued Stay Notice Immediate
Review - Attending Physician Concurs 6 1.74%
Total 345 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
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15) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeals Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Appeal Reviews
Urban 52 69.33% 88.92%
Rural 23 30.67% 10.90%
Unknown 0 0.00% 0.18%
Total 75 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Quality of Care Reviews
Urban 14 87.50% 92.84%
Rural 2 12.50% 6.58%
Unknown 0 0.00% 0.58%
Total 16 100.00% 100.00%
16) IMMEDIATE ADVOCACY REVIEWS
# of Beneficiary
Complaints # of Immediate Advocacy Reviews
(%) of Total Beneficiary
Complaints Resolved by
Immediate Advocacy
Immediate Advocacy Reviews
22
7
31.82%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
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LIVANTA QIO AREA #1 – STATE OF NEW JERSEY
1) TOTAL # OF REVIEWS
Review Type # of Reviews
Percent of
TOTAL
Reviews (%)
Coding Validation (120 - HWDRG) 1,951 14.11%
Coding Validation (All Other Selection Reasons) 15 0.11%
Quality of Care Review (101 through 104 -Beneficiary Complaint) 169 1.22%
Quality of Care Review (All Other Selection Reasons) 66 0.48%
Utilization (158 - FI/MAC Referral for Readmission Review) 0 0.00%
Utilization (All Other Selection Reasons) 4,177 30.21%
Notice of Non-coverage (105 through 108 - Admission and Preadmission) 92 0.67%
Notice of Non-coverage (118 - BIPA) 2,963 21.43%
Notice of Non-coverage (117 - Grijalva) 2,741 19.82%
Notice of Non-coverage (121 through 124 -Weichardt) 1,625 11.75%
Notice of Non-coverage (111-Request for QIO Concurrence) 14 0.10%
EMTALA 5 Day 13 0.09%
EMTALA 60 Day 0 0.00%
Total 13,826 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
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2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries
(%)
1. A419 - SEPSIS, UNSPECIFIED
ORGANISM 14,073 22.74%
2. 0389 - SEPTICEMIA NOS 7,922 12.80%
3. J189 - PNEUMONIA, UNSPECIFIED
ORGANISM 6,630 10.71%
4. J441 - CHRONIC OBSTRUCTIVE
PULMONARY DISEASE W (ACUTE)
EXACERBATION
5,828 9.42%
5. N179 - ACUTE KIDNEY FAILURE,
UNSPECIFIED 5,605 9.05%
6. N390 - URINARY TRACT INFECTION,
SITE NOT SPECIFIED 5,279 8.53%
7. I214 - NON-ST ELEVATION (NSTEMI)
MYOCARDIAL INFARCTION 5,191 8.39%
8. I5033 - ACUTE ON CHRONIC
DIASTOLIC (CONGESTIVE) HEART
FAILURE
4,129 6.67%
9. 486 - PNEUMONIA, ORGANISM NOS 3,733 6.03%
10. 5849 - ACUTE KIDNEY FAILURE NOS 3,510 5.67%
Total 61,900 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – N e w J e r s e y 50 | P a g e
3) BENEFICIARY DEMOGRAPHICS
Demographics # of Beneficiaries Percent of Beneficiaries
(%)
Sex/Gender
Female 5,176 58.70%
Male 3,617 41.02%
Unknown 25 0.28%
Total 8,818 100.00%
Race
Asian 143 1.62%
Black 1,262 14.31%
Hispanic 216 2.45%
North American Native 4 0.05%
Other 135 1.53%
Unknown 70 0.79%
White 6,988 79.25%
Total 8,818 100.00%
Age
Under 65 1,113 12.62%
65-70 1,103 12.51%
71-80 2,561 29.04%
81-90 2,987 33.87%
91+ 1,054 11.95%
Total 8,818 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – N e w J e r s e y 51 | P a g e
4) PROVIDER REVIEWS SETTINGS
Setting # of Providers Percent of
Providers (%)
0: Acute Care Unit of an Inpatient Facility 65 14.25%
1: Distinct Psychiatric Facility 5 1.10%
2: Distinct Rehabilitation Facility 9 1.97%
3: Distinct Skilled Nursing Facility 300 65.79%
5: Clinic 0 0.00%
6: Distinct Dialysis Center Facility 0 0.00%
7: Dialysis Center Unit of Inpatient Facility 0 0.00%
8: Independent Based RHC 0 0.00%
9: Provider Based RHC 0 0.00%
C: Free Standing Ambulatory Surgery Center 2 0.44%
G: End Stage Renal Disease Unit 0 0.00%
H: Home Health Agency 28 6.14%
N: Critical Access Hospital 0 0.00%
O: Setting Does Not Fit Into Any Other Existing Setting Code 0 0.00%
Q: Long Term Care Facility 8 1.75%
R: Hospice 37 8.11%
S: Psychiatric Unit of an Inpatient Facility 1 0.22%
T: Rehabilitation Unit of an Inpatient Facility 1 0.22%
U: Swing Bed Hospital Designation for Short-Term, Long-Term Care,
and Rehabilitation Hospitals 0 0.00%
Y: Federally Qualified Health Centers 0 0.00%
Z: Swing Bed Designation for Critical Access Hospitals 0 0.00%
Other 0 0.00%
Total 456 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
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5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C01: Apparently did not obtain pertinent
history and/or findings from examination 3 0 0.00% 3
C02: Apparently did not make appropriate
diagnoses and/or assessments 52 3 5.77% 1
C03: Apparently did not establish and/or
develop an appropriate treatment plan for a
defined problem or diagnosis which
prompted this episode of care [excludes
laboratory and/or imaging (see C06 or C09)
and procedures (see C07 or C08) and
consultations (see C13 and C14)
156 11 7.05% 1
C04: Apparently did not carry out an
established plan in a competent and/or
timely fashion
43 4 9.30% 3
C05: Apparently did not appropriately
assess and/or act on changes in
clinical/other status results
37 0 0.00% 2
C06: Apparently did not appropriately
assess and/or act on laboratory tests or
imaging study results
7 2 28.57% 1
C07: Apparently did not establish adequate
clinical justification for a procedure which
carries patient risk and was performed
13 7 53.85% 0
C08: Apparently did not perform a
procedure that was indicated (other than lab
and imaging, see C09)
4 0 0.00% 0
C09: Apparently did not obtain appropriate
laboratory tests and/or imaging studies 16 1 6.25% 0
C10: Apparently did not develop and
initiate appropriate discharge, follow-up,
and/or rehabilitation plans
35 8 22.86% 3
C11: Apparently did not demonstrate that
the patient was ready for discharge 33 3 9.09% 1
C12: Apparently did not provide
appropriate personnel and/or resources 0 0 0.00% 0
C13: Apparently did not order appropriate
specialty consultation 15 1 6.67% 0
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – N e w J e r s e y 53 | P a g e
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C14: Apparently specialty consultation
process was not completed in a timely
manner
4 3 75.00% 2
C15: Apparently did not effectively
coordinate across disciplines 6 1 16.67% 1
C16: Apparently did not ensure a safe
environment (medication errors, falls,
pressure ulcers, transfusion reactions,
nosocomial infection)
68 4 5.88% 0
C17: Apparently did not order/follow
evidence-based practices 8 1 12.50% 1
C18: Apparently did not provide medical
record documentation that impacts patient
care
2 0 0.00% 1
C40: Apparently did not follow up on
patient’s non-compliance 0 0 0.00% 0
C99: Other quality concern not elsewhere
classified 104 11 10.58% 1
Total 606 60 9.90% 21
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – N e w J e r s e y 54 | P a g e
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Review by Notification Type # of Reviews (%) of Total
105: Notice of Non-coverage FFS Preadmission Notice Concurrent
Immediate Review 2 0.03%
106: Notice of Non-coverage FFS Preadmission Notice Non-immediate
Review 0 0.00%
107: Notice of Non-coverage FFS Admission Notice Concurrent
Immediate Review 90 1.35%
108: Notice of Non-coverage FFS Admission Notice Non-immediate
Review 0 0.00%
111: Notice of Non-coverage Request for QIO Concurrence 13 0.19%
117: MA Appeal Review (CORF, HHA, SNF) 2,433 36.36%
118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 2,590 38.71%
121: Notice of Non-coverage Continued Stay Notice Immediate Review -
Attending Physician Concurs 1,052 15.72%
122: Notice of Non-coverage Continued Stay Notice Concurrent Non-
immediate Review 93 1.39%
123: Notice of Non-coverage Continued Stay Retrospective 219 3.27%
124: MA Notice of Non-coverage Continued Stay Notice Immediate
Review - Attending Physician Concurs 199 2.97%
Total 6,691 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – N e w J e r s e y 55 | P a g e
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeals Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Appeal Reviews
Urban 445 100.00% 88.92%
Rural 0 0.00% 10.90%
Unknown 0 0.00% 0.18%
Total 445 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Quality of Care Reviews
Urban 114 100.00% 92.84%
Rural 0 0.00% 6.58%
Unknown 0 0.00% 0.58%
Total 114 100.00% 100.00%
8) IMMEDIATE ADVOCACY REVIEWS
# of Beneficiary
Complaints # of Immediate Advocacy Reviews
(%) of Total Beneficiary
Complaints Resolved by
Immediate Advocacy
Immediate Advocacy Reviews
266 103
38.72%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
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LIVANTA QIO AREA #1 – STATE OF NEW YORK
1) TOTAL # OF REVIEWS
Review Type # of Reviews
Percent of
TOTAL
Reviews (%)
Coding Validation (120 - HWDRG) 3,214 12.57%
Coding Validation (All Other Selection Reasons) 0 0.00%
Quality of Care Review (101 through 104 -Beneficiary Complaint) 337 1.32%
Quality of Care Review (All Other Selection Reasons) 139 0.54%
Utilization (158 - FI/MAC Referral for Readmission Review) 0 0.00%
Utilization (All Other Selection Reasons) 8,420 32.92%
Notice of Non-coverage (105 through 108 - Admission and Preadmission) 813 3.18%
Notice of Non-coverage (118 - BIPA) 3,831 14.98%
Notice of Non-coverage (117 - Grijalva) 5,349 20.92%
Notice of Non-coverage (121 through 124 -Weichardt) 3,394 13.27%
Notice of Non-coverage (111-Request for QIO Concurrence) 51 0.20%
EMTALA 5 Day 26 0.10%
EMTALA 60 Day 0 0.00%
Total 25,574 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – N e w Y o r k 57 | P a g e
2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries
(%)
1. 0389 - SEPTICEMIA NOS 29,852 22.50%
2. A419 - SEPSIS, UNSPECIFIED
ORGANISM 26,934 20.30%
3. 486 - PNEUMONIA, ORGANISM NOS 13,246 9.98%
4. J189 - PNEUMONIA, UNSPECIFIED
ORGANISM 11,245 8.48%
5. 5990 - URIN TRACT INFECTION NOS 9,457 7.13%
6. 5849 - ACUTE KIDNEY FAILURE NOS 9,132 6.88%
7. J441 - CHRONIC OBSTRUCTIVE
PULMONARY DISEASE W (ACUTE)
EXACERBATION
8,878 6.69%
8. 49121 - OBS CHR BRONC W(AC) EXAC 8,083 6.09%
9. N390 - URINARY TRACT INFECTION,
SITE NOT SPECIFIED 7,995 6.03%
10. N179 - ACUTE KIDNEY FAILURE,
UNSPECIFIED 7,850 5.92%
Total 132,672 100.00%
3) BENEFICIARY DEMOGRAPHICS
Demographics # of Beneficiaries Percent of Beneficiaries
(%)
Sex/Gender
Female 9,836 60.30%
Male 6,407 39.28%
Unknown 68 0.42%
Total 16,311 100.00%
Race
Asian 282 1.73%
Black 2,399 14.71%
Hispanic 438 2.69%
North American Native 25 0.15%
Other 315 1.93%
Unknown 211 1.29%
White 12,641 77.50%
Total 16,311 100.00%
Age
Under 65 2,241 13.74%
65-70 2,048 12.56%
71-80 4,284 26.26%
81-90 5,558 34.08%
91+ 2,180 13.37%
Total 16,311 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – N e w Y o r k 58 | P a g e
4) PROVIDER REVIEWS SETTINGS
Setting # of Providers Percent of
Providers (%)
0: Acute Care Unit of an Inpatient Facility 158 19.75%
1: Distinct Psychiatric Facility 2 0.25%
2: Distinct Rehabilitation Facility 0 0.00%
3: Distinct Skilled Nursing Facility 512 64.00%
5: Clinic 0 0.00%
6: Distinct Dialysis Center Facility 1 0.13%
7: Dialysis Center Unit of Inpatient Facility 2 0.25%
8: Independent Based RHC 0 0.00%
9: Provider Based RHC 0 0.00%
C: Free Standing Ambulatory Surgery Center 0 0.00%
G: End Stage Renal Disease Unit 3 0.38%
H: Home Health Agency 78 9.75%
N: Critical Access Hospital 6 0.75%
O: Setting Does Not Fit Into Any Other Existing Setting Code 0 0.00%
Q: Long Term Care Facility 2 0.25%
R: Hospice 27 3.38%
S: Psychiatric Unit of an Inpatient Facility 2 0.25%
T: Rehabilitation Unit of an Inpatient Facility 3 0.38%
U: Swing Bed Hospital Designation for Short-Term, Long-Term Care,
and Rehabilitation Hospitals 2 0.25%
Y: Federally Qualified Health Centers 2 0.25%
Z: Swing Bed Designation for Critical Access Hospitals 0 0.00%
Other 0 0.00%
Total 800 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – N e w Y o r k 59 | P a g e
5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C01: Apparently did not obtain pertinent
history and/or findings from examination 2 1 50.00% 0
C02: Apparently did not make appropriate
diagnoses and/or assessments 102 16 15.69% 3
C03: Apparently did not establish and/or
develop an appropriate treatment plan for a
defined problem or diagnosis which
prompted this episode of care [excludes
laboratory and/or imaging (see C06 or C09)
and procedures (see C07 or C08) and
consultations (see C13 and C14)
271 17 6.27% 4
C04: Apparently did not carry out an
established plan in a competent and/or
timely fashion
98 11 11.22% 5
C05: Apparently did not appropriately
assess and/or act on changes in
clinical/other status results
43 6 13.95% 2
C06: Apparently did not appropriately
assess and/or act on laboratory tests or
imaging study results
13 2 15.38% 0
C07: Apparently did not establish adequate
clinical justification for a procedure which
carries patient risk and was performed
17 5 29.41% 0
C08: Apparently did not perform a
procedure that was indicated (other than lab
and imaging, see C09)
20 7 35.00% 0
C09: Apparently did not obtain appropriate
laboratory tests and/or imaging studies 24 3 12.50% 0
C10: Apparently did not develop and
initiate appropriate discharge, follow-up,
and/or rehabilitation plans
59 3 5.08% 1
C11: Apparently did not demonstrate that
the patient was ready for discharge 101 7 6.94% 1
C12: Apparently did not provide
appropriate personnel and/or resources 1 0 0.00% 1
C13: Apparently did not order appropriate
specialty consultation 30 0 0.00% 2
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – N e w Y o r k 60 | P a g e
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C14: Apparently specialty consultation
process was not completed in a timely
manner
5 0 0.00% 2
C15: Apparently did not effectively
coordinate across disciplines 21 2 9.52% 0
C16: Apparently did not ensure a safe
environment (medication errors, falls,
pressure ulcers, transfusion reactions,
nosocomial infection)
104 12 11.54% 1
C17: Apparently did not order/follow
evidence-based practices 12 1 8.33% 0
C18: Apparently did not provide medical
record documentation that impacts patient
care
3 1 33.33% 0
C40: Apparently did not follow up on
patient’s non-compliance 0 0 0.00% 0
C99: Other quality concern not elsewhere
classified 185 31 16.76% 10
Total 1,111 125 11.25% 32
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – N e w Y o r k 61 | P a g e
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Review by Notification Type # of Reviews (%) of Total
105: Notice of Non-coverage FFS Preadmission Notice Concurrent
Immediate Review 158 1.31%
106: Notice of Non-coverage FFS Preadmission Notice Non-immediate
Review 6 0.05%
107: Notice of Non-coverage FFS Admission Notice Concurrent
Immediate Review 649 5.38%
108: Notice of Non-coverage FFS Admission Notice Non-immediate
Review 4 0.03%
111: Notice of Non-coverage Request for QIO Concurrence 51 0.42%
117: MA Appeal Review (CORF, HHA, SNF) 4,534 37.58%
118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 3,429 28.42%
121: Notice of Non-coverage Continued Stay Notice Immediate Review -
Attending Physician Concurs 1,698 14.07%
122: Notice of Non-coverage Continued Stay Notice Concurrent Non-
immediate Review 165 1.37%
123: Notice of Non-coverage Continued Stay Retrospective 445 3.69%
124: MA Notice of Non-coverage Continued Stay Notice Immediate
Review - Attending Physician Concurs 926 7.68%
Total 12,065 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – N e w Y o r k 62 | P a g e
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeals Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Appeal Reviews
Urban 691 88.59% 88.92%
Rural 86 11.03% 10.90%
Unknown 3 0.38% 0.18%
Total 780 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Quality of Care Reviews
Urban 155 92.26% 92.84%
Rural 12 7.14% 6.58%
Unknown 1 0.60% 0.58%
Total 168 100.00% 100.00%
8) IMMEDIATE ADVOCACY REVIEWS
# of Beneficiary
Complaints # of Immediate Advocacy Reviews
(%) of Total Beneficiary
Complaints Resolved by
Immediate Advocacy
Immediate Advocacy Reviews
560
261
46.61%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – P e n n s y l v a n i a 63 | P a g e
LIVANTA QIO AREA #1 – STATE OF PENNSYLVANIA
1) TOTAL # OF REVIEWS
Review Type # of Reviews Percent of TOTAL
Reviews (%)
Coding Validation (120 - HWDRG) 1,740 7.34%
Coding Validation (All Other Selection Reasons) 0 0.00%
Quality of Care Review (101 through 104 -Beneficiary Complaint) 284 1.20%
Quality of Care Review (All Other Selection Reasons) 136 0.57%
Utilization (158 - FI/MAC Referral for Readmission Review) 0 0.00%
Utilization (All Other Selection Reasons) 3,791 15.99%
Notice of Non-coverage (105 through 108 - Admission and
Preadmission) 11 0.05%
Notice of Non-coverage (118 - BIPA) 3,974 16.76%
Notice of Non-coverage (117 - Grijalva) 12,429 52.42%
Notice of Non-coverage (121 through 124 -Weichardt) 1,342 5.66%
Notice of Non-coverage (111-Request for QIO Concurrence) 2 0.01%
EMTALA 5 Day 0 0.00%
EMTALA 60 Day 0 0.00%
Total 23,709 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – P e n n s y l v a n i a 64 | P a g e
2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries
(%)
1. A419 - SEPSIS, UNSPECIFIED
ORGANISM 18,118 22.63%
2. 0389 - SEPTICEMIA NOS 9,084 11.35%
3. J189 - PNEUMONIA, UNSPECIFIED
ORGANISM 8,907 11.12%
4. N179 - ACUTE KIDNEY FAILURE,
UNSPECIFIED 7,621 9.52%
5. J441 - CHRONIC OBSTRUCTIVE
PULMONARY DISEASE W (ACUTE)
EXACERBATION
7,454 9.31%
6. I214 - NON-ST ELEVATION (NSTEMI)
MYOCARDIAL INFARCTION 6,442 8.05%
7. V5789 - REHABILITATION PROC NEC 6,360 7.94%
8. N390 - URINARY TRACT INFECTION,
SITE NOT SPECIFIED 6,081 7.59%
9. I5033 - ACUTE ON CHRONIC
DIASTOLIC (CONGESTIVE) HEART
FAILURE
5,537 6.92%
10. 486 - PNEUMONIA, ORGANISM NOS 4,462 5.57%
Total 80,066 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – P e n n s y l v a n i a 65 | P a g e
3) BENEFICIARY DEMOGRAPHICS
Demographics # of Beneficiaries Percent of Beneficiaries
(%)
Sex/Gender
Female 10,394 61.10%
Male 6,459 37.97%
Unknown 158 0.93%
Total 17,011 100.00%
Race
Asian 83 0.49%
Black 1,745 10.26%
Hispanic 76 0.45%
North American Native 4 0.02%
Other 85 0.50%
Unknown 213 1.25%
White 14,805 87.03%
Total 17,011 100.00%
Age
Under 65 2,058 12.10%
65-70 2,091 12.29%
71-80 4,519 26.57%
81-90 6,165 36.24%
91+ 2,178 12.80%
Total 17,011 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – P e n n s y l v a n i a 66 | P a g e
4) PROVIDER REVIEWS SETTINGS
Setting # of Providers Percent of
Providers (%)
0: Acute Care Unit of an Inpatient Facility 140 14.11%
1: Distinct Psychiatric Facility 5 0.50%
2: Distinct Rehabilitation Facility 23 2.32%
3: Distinct Skilled Nursing Facility 648 65.32%
5: Clinic 0 0.00%
6: Distinct Dialysis Center Facility 1 0.10%
7: Dialysis Center Unit of Inpatient Facility 0 0.00%
8: Independent Based RHC 0 0.00%
9: Provider Based RHC 0 0.00%
C: Free Standing Ambulatory Surgery Center 1 0.10%
G: End Stage Renal Disease Unit 1 0.10%
H: Home Health Agency 76 7.66%
N: Critical Access Hospital 5 0.50%
O: Setting Does Not Fit Into Any Other Existing Setting Code 0 0.00%
Q: Long Term Care Facility 18 1.81%
R: Hospice 73 7.36%
S: Psychiatric Unit of an Inpatient Facility 1 0.10%
T: Rehabilitation Unit of an Inpatient Facility 0 0.00%
U: Swing Bed Hospital Designation for Short-Term, Long-Term Care,
and Rehabilitation Hospitals 0 0.00%
Y: Federally Qualified Health Centers 0 0.00%
Z: Swing Bed Designation for Critical Access Hospitals 0 0.00%
Other 0 0.00%
Total 992 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – P e n n s y l v a n i a 67 | P a g e
5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C01: Apparently did not obtain pertinent
history and/or findings from examination 3 0 0.00% 0
C02: Apparently did not make appropriate
diagnoses and/or assessments 71 9 12.68% 4
C03: Apparently did not establish and/or
develop an appropriate treatment plan for a
defined problem or diagnosis which
prompted this episode of care [excludes
laboratory and/or imaging (see C06 or C09)
and procedures (see C07 or C08) and
consultations (see C13 and C14)
236 22 9.32% 3
C04: Apparently did not carry out an
established plan in a competent and/or
timely fashion
80 9 11.25% 5
C05: Apparently did not appropriately
assess and/or act on changes in
clinical/other status results
44 5 11.36% 7
C06: Apparently did not appropriately
assess and/or act on laboratory tests or
imaging study results
6 3 50.00% 0
C07: Apparently did not establish adequate
clinical justification for a procedure which
carries patient risk and was performed
11 1 9.09% 0
C08: Apparently did not perform a
procedure that was indicated (other than lab
and imaging, see C09)
11 2 18.18% 0
C09: Apparently did not obtain appropriate
laboratory tests and/or imaging studies 29 1 3.45% 1
C10: Apparently did not develop and
initiate appropriate discharge, follow-up,
and/or rehabilitation plans
50 5 10.00% 0
C11: Apparently did not demonstrate that
the patient was ready for discharge 89 4 4.49% 0
C12: Apparently did not provide
appropriate personnel and/or resources 1 1 100.00% 0
C13: Apparently did not order appropriate
specialty consultation 17 2 11.76% 1
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – P e n n s y l v a n i a 68 | P a g e
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C14: Apparently specialty consultation
process was not completed in a timely
manner
8 0 0.00% 1
C15: Apparently did not effectively
coordinate across disciplines 14 1 7.14% 1
C16: Apparently did not ensure a safe
environment (medication errors, falls,
pressure ulcers, transfusion reactions,
nosocomial infection)
88 9 10.23% 1
C17: Apparently did not order/follow
evidence-based practices 18 2 11.11% 1
C18: Apparently did not provide medical
record documentation that impacts patient
care
5 2 40.00% 1
C40: Apparently did not follow up on
patient’s non-compliance 0 0 0.00% 0
C99: Other quality concern not elsewhere
classified 138 18 13.04% 1
Total 919 96 10.45% 27
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – P e n n s y l v a n i a 69 | P a g e
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE.
Appeal Review by Notification Type # of Reviews (%) of Total
105: Notice of Non-coverage FFS Preadmission Notice Concurrent
Immediate Review 0 0.00%
106: Notice of Non-coverage FFS Preadmission Notice Non-immediate
Review 0 0.00%
107: Notice of Non-coverage FFS Admission Notice Concurrent
Immediate Review 10 0.06%
108: Notice of Non-coverage FFS Admission Notice Non-immediate
Review 0 0.00%
111: Notice of Non-coverage Request for QIO Concurrence 2 0.01%
117: MA Appeal Review (CORF, HHA, SNF) 11,397 70.02%
118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 3,630 22.30%
121: Notice of Non-coverage Continued Stay Notice Immediate Review -
Attending Physician Concurs 579 3.56%
122: Notice of Non-coverage Continued Stay Notice Concurrent Non-
immediate Review 57 0.35%
123: Notice of Non-coverage Continued Stay Retrospective 119 0.73%
124: MA Notice of Non-coverage Continued Stay Notice Immediate
Review - Attending Physician Concurs 482 2.96%
Total 16,276 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – P e n n s y l v a n i a 70 | P a g e
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeals Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Appeal Reviews
Urban 802 83.72% 88.92%
Rural 156 16.28% 10.90%
Unknown 0 0.00% 0.18%
Total 958 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Quality of Care Reviews
Urban 169 88.48% 92.84%
Rural 21 10.99% 6.58%
Unknown 1 0.52% 0.58%
Total 191 100.00% 100.00%
8) IMMEDIATE ADVOCACY REVIEWS
# of Beneficiary
Complaints # of Immediate Advocacy Reviews
(%) of Total Beneficiary
Complaints Resolved by
Immediate Advocacy
Immediate Advocacy Reviews
387
123
31.78%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
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LIVANTA QIO AREA #1 – PUERTO RICO
1) TOTAL # OF REVIEWS
Review Type # of Reviews
Percent of
TOTAL
Reviews (%)
Coding Validation (120 - HWDRG) 71 13.50%
Coding Validation (All Other Selection Reasons) 0 0.00%
Quality of Care Review (101 through 104 -Beneficiary Complaint) 46 8.75%
Quality of Care Review (All Other Selection Reasons) 16 3.04%
Utilization (158 - FI/MAC Referral for Readmission Review) 0 0.00%
Utilization (All Other Selection Reasons) 198 37.64%
Notice of Non-coverage (105 through 108 - Admission and Preadmission) 0 0.00%
Notice of Non-coverage (118 - BIPA) 21 3.99%
Notice of Non-coverage (117 - Grijalva) 37 7.03%
Notice of Non-coverage (121 through 124 -Weichardt) 137 26.05%
Notice of Non-coverage (111-Request for QIO Concurrence) 0 0.00%
EMTALA 5 Day 0 0.00%
EMTALA 60 Day 0 0.00%
Total 526 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
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2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries
(%)
1. I214 - NON-ST ELEVATION (NSTEMI)
MYOCARDIAL INFARCTION 636 16.65%
2. N390 - URINARY TRACT INFECTION,
SITE NOT SPECIFIED 490 12.83%
3. A419 - SEPSIS, UNSPECIFIED
ORGANISM 453 11.86%
4. J189 - PNEUMONIA, UNSPECIFIED
ORGANISM 441 11.54%
5. J441 - CHRONIC OBSTRUCTIVE
PULMONARY DISEASE W (ACUTE)
EXACERBATION
397 10.39%
6. I509 - HEART FAILURE, UNSPECIFIED 300 7.85%
7. J180 - BRONCHOPNEUMONIA,
UNSPECIFIED ORGANISM 298 7.80%
8. D649 - ANEMIA, UNSPECIFIED 293 7.67%
9. I639 - CEREBRAL INFARCTION,
UNSPECIFIED 259 6.78%
10. I25110 - ATHSCL HEART DISEASE OF
NATIVE COR ART W UNSTABLE ANG
PCTRS
253 6.62%
Total 3,820 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – P u e r t o R i c o 73 | P a g e
3) BENEFICIARY DEMOGRAPHICS
Demographics # of Beneficiaries Percent of Beneficiaries
(%)
Sex/Gender
Female 176 53.17%
Male 151 45.62%
Unknown 4 1.21%
Total 331 100.00%
Race
Asian 0 0.00%
Black 18 5.44%
Hispanic 58 17.52%
North American Native 0 0.00%
Other 13 3.93%
Unknown 6 1.81%
White 236 71.30%
Total 331 100.00%
Age
Under 65 64 19.34%
65-70 55 16.62%
71-80 114 34.44%
81-90 77 23.26%
91+ 21 6.34%
Total 331 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – P u e r t o R i c o 74 | P a g e
4) PROVIDER REVIEWS SETTINGS
Setting # of Providers Percent of
Providers (%)
0: Acute Care Unit of an Inpatient Facility 37 54.41%
1: Distinct Psychiatric Facility 2 2.94%
2: Distinct Rehabilitation Facility 2 2.94%
3: Distinct Skilled Nursing Facility 3 4.41%
5: Clinic 0 0.00%
6: Distinct Dialysis Center Facility 1 1.47%
7: Dialysis Center Unit of Inpatient Facility 0 0.00%
8: Independent Based RHC 0 0.00%
9: Provider Based RHC 0 0.00%
C: Free Standing Ambulatory Surgery Center 0 0.00%
G: End Stage Renal Disease Unit 0 0.00%
H: Home Health Agency 9 13.24%
N: Critical Access Hospital 0 0.00%
O: Setting Does Not Fit Into Any Other Existing Setting Code 0 0.00%
Q: Long Term Care Facility 0 0.00%
R: Hospice 14 20.59%
S: Psychiatric Unit of an Inpatient Facility 0 0.00%
T: Rehabilitation Unit of an Inpatient Facility 0 0.00%
U: Swing Bed Hospital Designation for Short-Term, Long-Term Care,
and Rehabilitation Hospitals 0 0.00%
Y: Federally Qualified Health Centers 0 0.00%
Z: Swing Bed Designation for Critical Access Hospitals 0 0.00%
Other 0 0.00%
Total 68 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – P u e r t o R i c o 75 | P a g e
5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C01: Apparently did not obtain pertinent
history and/or findings from examination 1 0 0.00% 0
C02: Apparently did not make appropriate
diagnoses and/or assessments 25 3 12.00% 2
C03: Apparently did not establish and/or
develop an appropriate treatment plan for a
defined problem or diagnosis which
prompted this episode of care [excludes
laboratory and/or imaging (see C06 or C09)
and procedures (see C07 or C08) and
consultations (see C13 and C14)
46 5 10.87% 0
C04: Apparently did not carry out an
established plan in a competent and/or
timely fashion
19 4 21.05% 1
C05: Apparently did not appropriately
assess and/or act on changes in
clinical/other status results
9 2 22.22% 1
C06: Apparently did not appropriately
assess and/or act on laboratory tests or
imaging study results
5 4 80.00% 0
C07: Apparently did not establish adequate
clinical justification for a procedure which
carries patient risk and was performed
0 0 0.00% 0
C08: Apparently did not perform a
procedure that was indicated (other than lab
and imaging, see C09)
0 0 0.00% 0
C09: Apparently did not obtain appropriate
laboratory tests and/or imaging studies 8 2 25.00% 0
C10: Apparently did not develop and
initiate appropriate discharge, follow-up,
and/or rehabilitation plans
8 0 0.00% 3
C11: Apparently did not demonstrate that
the patient was ready for discharge 17 5 29.41% 0
C12: Apparently did not provide
appropriate personnel and/or resources 0 0 0.00% 0
C13: Apparently did not order appropriate
specialty consultation 5 2 40.00% 0
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – P u e r t o R i c o 76 | P a g e
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C14: Apparently specialty consultation
process was not completed in a timely
manner
1 0 0.00% 0
C15: Apparently did not effectively
coordinate across disciplines 2 1 50.00% 2
C16: Apparently did not ensure a safe
environment (medication errors, falls,
pressure ulcers, transfusion reactions,
nosocomial infection)
18 4 22.22% 2
C17: Apparently did not order/follow
evidence-based practices 2 0 0.00% 0
C18: Apparently did not provide medical
record documentation that impacts patient
care
0 0 0.00% 0
C40: Apparently did not follow up on
patient’s non-compliance 0 0 0.00% 0
C99: Other quality concern not elsewhere
classified 16 0 12.50% 0
Total 182 34 18.68% 11
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – P u e r t o R i c o 77 | P a g e
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Review by Notification Type # of Reviews (%) of Total
105: Notice of Non-coverage FFS Preadmission Notice Concurrent
Immediate Review 0 0.00%
106: Notice of Non-coverage FFS Preadmission Notice Non-immediate
Review 0 0.00%
107: Notice of Non-coverage FFS Admission Notice Concurrent
Immediate Review 0 0.00%
108: Notice of Non-coverage FFS Admission Notice Non-immediate
Review 0 0.00%
111: Notice of Non-coverage Request for QIO Concurrence 0 0.00%
117: MA Appeal Review (CORF, HHA, SNF) 27 15.17%
118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 18 10.11%
121: Notice of Non-coverage Continued Stay Notice Immediate Review -
Attending Physician Concurs 19 10.67%
122: Notice of Non-coverage Continued Stay Notice Concurrent Non-
immediate Review 6 3.37%
123: Notice of Non-coverage Continued Stay Retrospective 10 5.62%
124: MA Notice of Non-coverage Continued Stay Notice Immediate
Review - Attending Physician Concurs 98 55.06%
Total 178 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – P u e r t o R i c o 78 | P a g e
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeals Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Appeal Reviews
Urban 47 97.92% 88.92%
Rural 1 2.08% 10.90%
Unknown 0 0.00% 0.18%
Total 48 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Quality of Care Reviews
Urban 40 97.56% 92.84%
Rural 1 2.44% 6.58%
Unknown 0 0.00% 0.58%
Total 41 100.00% 100.00%
8) IMMEDIATE ADVOCACY REVIEWS
# of Beneficiary
Complaints # of Immediate Advocacy Reviews
(%) of Total Beneficiary
Complaints Resolved by
Immediate Advocacy
Immediate Advocacy Reviews
80
36
48.75%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
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LIVANTA QIO AREA #1 – STATE OF RHODE ISLAND
1) TOTAL # OF REVIEWS
Review Type # of Reviews
Percent of
TOTAL
Reviews (%)
Coding Validation (120 - HWDRG) 90 5.75%
Coding Validation (All Other Selection Reasons) 0 0.00%
Quality of Care Review (101 through 104 -Beneficiary Complaint) 36 2.30%
Quality of Care Review (All Other Selection Reasons) 8 0.51%
Utilization (158 - FI/MAC Referral for Readmission Review) 0 0.00%
Utilization (All Other Selection Reasons) 441 28.18%
Notice of Non-coverage (105 through 108 - Admission and Preadmission) 62 3.96%
Notice of Non-coverage (118 - BIPA) 195 12.46%
Notice of Non-coverage (117 - Grijalva) 504 32.20%
Notice of Non-coverage (121 through 124 -Weichardt) 227 14.50%
Notice of Non-coverage (111-Request for QIO Concurrence) 1 0.06%
EMTALA 5 Day 1 0.06%
EMTALA 60 Day 0 0.00%
Total 1,565 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – R h o d e I s l a n d 80 | P a g e
2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries
(%)
1. 0389 - SEPTICEMIA NOS 1,838 22.08%
2. A419 - SEPSIS, UNSPECIFIED
ORGANISM 1,418 17.03%
3. J441 - CHRONIC OBSTRUCTIVE
PULMONARY DISEASE W (ACUTE)
EXACERBATION
710 8.53%
4. 5849 - ACUTE KIDNEY FAILURE NOS 681 8.18%
5. 41071 - SUBENDO INFARCT, INITIAL 631 7.58%
6. 49121 - OBS CHR BRONC W(AC) EXAC 626 7.52%
7. 486 - PNEUMONIA, ORGANISM NOS 618 7.42%
8. 5990 - URIN TRACT INFECTION NOS 617 7.41%
9. 42833 - AC ON CHR DIAST HRT FAIL 598 7.18%
10. 71536 - LOC OSTEOARTH NOS-L/LEG 588 7.06%
Total 8,325 100.00%
3) BENEFICIARY DEMOGRAPHICS
Demographics # of Beneficiaries Percent of Beneficiaries
(%)
Sex/Gender
Female 644 60.19%
Male 422 39.44%
Unknown 4 0.37%
Total 1,070 100.00%
Race
Asian 4 0.37%
Black 42 3.93%
Hispanic 13 1.21%
North American Native 1 0.09%
Other 6 0.56%
Unknown 7 0.65%
White 997 93.18%
Total 1,070 100.00%
Age
Under 65 169 15.79%
65-70 112 10.47%
71-80 250 23.36%
81-90 374 34.95%
91+ 165 15.42%
Total 1,070 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – R h o d e I s l a n d 81 | P a g e
4) PROVIDER REVIEWS SETTINGS
Setting # of Providers Percent of
Providers (%)
0: Acute Care Unit of an Inpatient Facility 10 10.31%
1: Distinct Psychiatric Facility 1 1.03%
2: Distinct Rehabilitation Facility 1 1.03%
3: Distinct Skilled Nursing Facility 71 72.30%
5: Clinic 0 0.00%
6: Distinct Dialysis Center Facility 0 0.00%
7: Dialysis Center Unit of Inpatient Facility 0 0.00%
8: Independent Based RHC 0 0.00%
9: Provider Based RHC 0 0.00%
C: Free Standing Ambulatory Surgery Center 0 0.00%
G: End Stage Renal Disease Unit 0 0.00%
H: Home Health Agency 11 11.34%
N: Critical Access Hospital 0 0.00%
O: Setting Does Not Fit Into Any Other Existing Setting Code 0 0.00%
Q: Long Term Care Facility 0 0.00%
R: Hospice 3 3.09%
S: Psychiatric Unit of an Inpatient Facility 0 0.00%
T: Rehabilitation Unit of an Inpatient Facility 0 0.00%
U: Swing Bed Hospital Designation for Short-Term, Long-Term Care,
and Rehabilitation Hospitals 0 0.00%
Y: Federally Qualified Health Centers 0 0.00%
Z: Swing Bed Designation for Critical Access Hospitals 0 0.00%
Other 0 0.00%
Total 97 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – R h o d e I s l a n d 82 | P a g e
5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C01: Apparently did not obtain pertinent
history and/or findings from examination 0 0 0.00% 0
C02: Apparently did not make appropriate
diagnoses and/or assessments 8 0 0.00% 2
C03: Apparently did not establish and/or
develop an appropriate treatment plan for a
defined problem or diagnosis which
prompted this episode of care [excludes
laboratory and/or imaging (see C06 or C09)
and procedures (see C07 or C08) and
consultations (see C13 and C14)
33 2 6.06% 0
C04: Apparently did not carry out an
established plan in a competent and/or
timely fashion
9 0 0.00% 0
C05: Apparently did not appropriately
assess and/or act on changes in
clinical/other status results
2 0 0.00% 0
C06: Apparently did not appropriately
assess and/or act on laboratory tests or
imaging study results
1 0 0.00% 0
C07: Apparently did not establish adequate
clinical justification for a procedure which
carries patient risk and was performed
1 0 0.00% 0
C08: Apparently did not perform a
procedure that was indicated (other than lab
and imaging, see C09)
0 0 0.00% 0
C09: Apparently did not obtain appropriate
laboratory tests and/or imaging studies 0 0 0.00% 0
C10: Apparently did not develop and
initiate appropriate discharge, follow-up,
and/or rehabilitation plans
3 1 33.33% 0
C11: Apparently did not demonstrate that
the patient was ready for discharge 11 0 0.00% 0
C12: Apparently did not provide
appropriate personnel and/or resources 0 0 0.00% 0
C13: Apparently did not order appropriate
specialty consultation 1 0 0.00% 0
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – R h o d e I s l a n d 83 | P a g e
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C14: Apparently specialty consultation
process was not completed in a timely
manner
0 0 0.00% 0
C15: Apparently did not effectively
coordinate across disciplines 1 0 0.00% 0
C16: Apparently did not ensure a safe
environment (medication errors, falls,
pressure ulcers, transfusion reactions,
nosocomial infection)
6 0 0.00% 0
C17: Apparently did not order/follow
evidence-based practices 3 0 0.00% 0
C18: Apparently did not provide medical
record documentation that impacts patient
care
0 0 0.00% 0
C40: Apparently did not follow up on
patient’s non-compliance 0 0 0.00% 0
C99: Other quality concern not elsewhere
classified 15 4 26.67% 0
Total 94 7 7.45% 2
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – R h o d e I s l a n d 84 | P a g e
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Review by Notification Type # of Reviews (%) of Total
105: Notice of Non-coverage FFS Preadmission Notice Concurrent
Immediate Review 22 2.50%
106: Notice of Non-coverage FFS Preadmission Notice Non-immediate
Review 0 0.00%
107: Notice of Non-coverage FFS Admission Notice Concurrent
Immediate Review 39 4.44%
108: Notice of Non-coverage FFS Admission Notice Non-immediate
Review 0 0.00%
111: Notice of Non-coverage Request for QIO Concurrence 1 0.11%
117: MA Appeal Review (CORF, HHA, SNF) 439 49.94%
118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 177 20.14%
121: Notice of Non-coverage Continued Stay Notice Immediate Review -
Attending Physician Concurs 114 12.97%
122: Notice of Non-coverage Continued Stay Notice Concurrent Non-
immediate Review 7 0.80%
123: Notice of Non-coverage Continued Stay Retrospective 21 2.39%
124: MA Notice of Non-coverage Continued Stay Notice Immediate
Review - Attending Physician Concurs 59 6.71%
Total 879 100.00%
BFCC-QIO 11th
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08/01/2015 – 07/31/2016
A r e a 1 – R h o d e I s l a n d 85 | P a g e
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeals Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Appeal Reviews
Urban 96 100.00% 88.92%
Rural 0 0.00% 10.90%
Unknown 0 0.00% 0.18%
Total 96 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Quality of Care Reviews
Urban 10 100.00% 92.84%
Rural 0 0.00% 6.58%
Unknown 0 0.00% 0.58%
Total 10 100.00% 100.00%
8) IMMEDIATE ADVOCACY REVIEWS
# of Beneficiary
Complaints # of Immediate Advocacy Reviews
(%) of Total Beneficiary
Complaints Resolved by
Immediate Advocacy
Immediate Advocacy Reviews
34
7
20.59%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V i r g i n I s l a n d s 86 | P a g e
LIVANTA QIO AREA #1 – US VIRGIN ISLANDS
1) TOTAL # OF REVIEWS
Review Type # of Reviews
Percent of
TOTAL
Reviews (%)
Coding Validation (120 - HWDRG) 4 8.89%
Coding Validation (All Other Selection Reasons) 0 0.00%
Quality of Care Review (101 through 104 -Beneficiary Complaint) 6 13.33%
Quality of Care Review (All Other Selection Reasons) 0 0.00%
Utilization (158 - FI/MAC Referral for Readmission Review) 0 0.00%
Utilization (All Other Selection Reasons) 22 48.89%
Notice of Non-coverage (105 through 108 - Admission and Preadmission) 0 0.00%
Notice of Non-coverage (118 - BIPA) 0 0.00%
Notice of Non-coverage (117 - Grijalva) 0 0.00%
Notice of Non-coverage (121 through 124 -Weichardt) 13 28.89%
Notice of Non-coverage (111-Request for QIO Concurrence) 0 0.00%
EMTALA 5 Day 0 0.00%
EMTALA 60 Day 0 0.00%
Total 45 0.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V i r g i n I s l a n d s 87 | P a g e
2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries
(%)
1. I639 - CEREBRAL INFARCTION,
UNSPECIFIED 43 17.00%
2. J189 - PNEUMONIA, UNSPECIFIED
ORGANISM 31 12.25%
3. I509 - HEART FAILURE, UNSPECIFIED 30 11.86%
4. N390 - URINARY TRACT INFECTION,
SITE NOT SPECIFIED 30 11.86%
5. 43491 - CRBL ART OCL NOS W INFRC 26 10.28%
6. I5023 - ACUTE ON CHRONIC SYSTOLIC
(CONGESTIVE) HEART FAILURE 24 9.49%
7. I214 - NON-ST ELEVATION (NSTEMI)
MYOCARDIAL INFARCTION 21 8.30%
8. I638 - OTHER CEREBRAL INFARCTION 17 6.72%
9. E860 - DEHYDRATION 16 6.32%
10. I4891 - UNSPECIFIED ATRIAL
FIBRILLATION 15 5.93%
Total 253 100.00%
3) BENEFICIARY DEMOGRAPHICS
Demographics # of Beneficiaries Percent of Beneficiaries
(%)
Sex/Gender
Female 14 43.75%
Male 18 56.25%
Unknown 0 0.00%
Total 32 100.00%
Race
Asian 0 0.00%
Black 21 65.63%
Hispanic 3 9.38%
North American Native 0 0.00%
Other 1 3.13%
Unknown 0 0.00%
White 7 21.88%
Total 32 100.00%
Age
Under 65 0 0.00%
65-70 8 25.00%
71-80 14 43.75%
81-90 9 28.13%
91+ 1 3.13%
Total 32 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V i r g i n I s l a n d s 88 | P a g e
4) PROVIDER REVIEWS SETTINGS
Setting # of Providers Percent of
Providers (%)
0: Acute Care Unit of an Inpatient Facility 2 100.00%
1: Distinct Psychiatric Facility 0 0.00%
2: Distinct Rehabilitation Facility 0 0.00%
3: Distinct Skilled Nursing Facility 0 0.00%
5: Clinic 0 0.00%
6: Distinct Dialysis Center Facility 0 0.00%
7: Dialysis Center Unit of Inpatient Facility 0 0.00%
8: Independent Based RHC 0 0.00%
9: Provider Based RHC 0 0.00%
C: Free Standing Ambulatory Surgery Center 0 0.00%
G: End Stage Renal Disease Unit 0 0.00%
H: Home Health Agency 0 0.00%
N: Critical Access Hospital 0 0.00%
O: Setting Does Not Fit Into Any Other Existing Setting Code 0 0.00%
Q: Long Term Care Facility 0 0.00%
R: Hospice 0 0.00%
S: Psychiatric Unit of an Inpatient Facility 0 0.00%
T: Rehabilitation Unit of an Inpatient Facility 0 0.00%
U: Swing Bed Hospital Designation for Short-Term, Long-Term Care,
and Rehabilitation Hospitals 0 0.00%
Y: Federally Qualified Health Centers 0 0.00%
Z: Swing Bed Designation for Critical Access Hospitals 0 0.00%
Other 0 0.00%
Total 2 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V i r g i n I s l a n d s 89 | P a g e
5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C01: Apparently did not obtain pertinent
history and/or findings from examination 0 0 0.00% 0
C02: Apparently did not make appropriate
diagnoses and/or assessments 1 0 0.00% 0
C03: Apparently did not establish and/or
develop an appropriate treatment plan for a
defined problem or diagnosis which
prompted this episode of care [excludes
laboratory and/or imaging (see C06 or C09)
and procedures (see C07 or C08) and
consultations (see C13 and C14)
2 0 0.00% 0
C04: Apparently did not carry out an
established plan in a competent and/or
timely fashion
1 0 0.00% 0
C05: Apparently did not appropriately
assess and/or act on changes in
clinical/other status results
3 0 0.00% 0
C06: Apparently did not appropriately
assess and/or act on laboratory tests or
imaging study results
1 0 0.00% 0
C07: Apparently did not establish adequate
clinical justification for a procedure which
carries patient risk and was performed
0 0 0.00% 0
C08: Apparently did not perform a
procedure that was indicated (other than lab
and imaging, see C09)
0 0 0.00% 0
C09: Apparently did not obtain appropriate
laboratory tests and/or imaging studies 2 0 0.00% 0
C10: Apparently did not develop and
initiate appropriate discharge, follow-up,
and/or rehabilitation plans
1 0 0.00% 0
C11: Apparently did not demonstrate that
the patient was ready for discharge 0 0 0.00% 0
C12: Apparently did not provide
appropriate personnel and/or resources 0 0 0.00% 0
C13: Apparently did not order appropriate
specialty consultation 0 0 0.00% 0
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V i r g i n I s l a n d s 90 | P a g e
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C14: Apparently specialty consultation
process was not completed in a timely
manner
0 0 0.00% 0
C15: Apparently did not effectively
coordinate across disciplines 0 0 0.00% 0
C16: Apparently did not ensure a safe
environment (medication errors, falls,
pressure ulcers, transfusion reactions,
nosocomial infection)
0 0 0.00% 0
C17: Apparently did not order/follow
evidence-based practices 0 0 0.00% 0
C18: Apparently did not provide medical
record documentation that impacts patient
care
0 0 0.00% 0
C40: Apparently did not follow up on
patient’s non-compliance 0 0 0.00% 0
C99: Other quality concern not elsewhere
classified 1 0 0.00% 0
Total 12 0 0.00% 0
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V i r g i n I s l a n d s 91 | P a g e
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Review by Notification Type # of Reviews (%) of Total
105: Notice of Non-coverage FFS Preadmission Notice Concurrent
Immediate Review 0 0.00%
106: Notice of Non-coverage FFS Preadmission Notice Non-immediate
Review 0 0.00%
107: Notice of Non-coverage FFS Admission Notice Concurrent
Immediate Review 0 0.00%
108: Notice of Non-coverage FFS Admission Notice Non-immediate
Review 0 0.00%
111: Notice of Non-coverage Request for QIO Concurrence 0 0.00%
117: MA Appeal Review (CORF, HHA, SNF) 0 0.00%
118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 0 0.00%
121: Notice of Non-coverage Continued Stay Notice Immediate Review -
Attending Physician Concurs 6 46.15%
122: Notice of Non-coverage Continued Stay Notice Concurrent Non-
immediate Review 4 30.77%
123: Notice of Non-coverage Continued Stay Retrospective 3 23.08%
124: MA Notice of Non-coverage Continued Stay Notice Immediate
Review - Attending Physician Concurs 0 0.00%
Total 13 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V i r g i n I s l a n d s 92 | P a g e
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeals Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Appeal Reviews
Urban 0 0.00% 88.92%
Rural 2 100.00% 10.90%
Unknown 0 0.00% 0.18%
Total 2 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Quality of Care Reviews
Urban 0 0.00% 92.84%
Rural 1 100.00% 6.58%
Unknown 0 0.00% 0.58%
Total 1 100.00% 100.00%
8) IMMEDIATE ADVOCACY REVIEWS
# of Beneficiary
Complaints # of Immediate Advocacy Reviews
(%) of Total Beneficiary
Complaints Resolved by
Immediate Advocacy
Immediate Advocacy Reviews
8
3
37.50%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V e r m o n t 93 | P a g e
LIVANTA QIO AREA #1 – STATE OF VERMONT
1) TOTAL # OF REVIEWS
Review Type # of Reviews
Percent of
TOTAL
Reviews (%)
Coding Validation (120 - HWDRG) 4 8.89%
Coding Validation (All Other Selection Reasons) 0 0.00%
Quality of Care Review (101 through 104 -Beneficiary Complaint) 6 13.33%
Quality of Care Review (All Other Selection Reasons) 0 0.00%
Utilization (158 - FI/MAC Referral for Readmission Review) 0 0.00%
Utilization (All Other Selection Reasons) 22 48.89%
Notice of Non-coverage (105 through 108 - Admission and Preadmission) 0 0.00%
Notice of Non-coverage (118 - BIPA) 0 0.00%
Notice of Non-coverage (117 - Grijalva) 0 0.00%
Notice of Non-coverage (121 through 124 -Weichardt) 13 28.89%
Notice of Non-coverage (111-Request for QIO Concurrence) 0 0.00%
EMTALA 5 Day 0 0.00%
EMTALA 60 Day 0 0.00%
Total 45 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V e r m o n t 94 | P a g e
2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses # of Beneficiaries Percent of Beneficiaries
(%)
1. A419 - SEPSIS, UNSPECIFIED
ORGANISM 838 21.38%
2. J189 - PNEUMONIA, UNSPECIFIED
ORGANISM 548 13.98%
3. I214 - NON-ST ELEVATION (NSTEMI)
MYOCARDIAL INFARCTION 432 11.02%
4. J441 - CHRONIC OBSTRUCTIVE
PULMONARY DISEASE W (ACUTE)
EXACERBATION
420 10.71%
5. 0389 - SEPTICEMIA NOS 333 8.49%
6. N390 - URINARY TRACT INFECTION,
SITE NOT SPECIFIED 287 7.32%
7. N179 - ACUTE KIDNEY FAILURE,
UNSPECIFIED 286 7.30%
8. 486 - PNEUMONIA, ORGANISM NOS 263 6.71%
9. I5033 - ACUTE ON CHRONIC
DIASTOLIC (CONGESTIVE) HEART
FAILURE
262 6.68%
10. M1711 - UNILATERAL PRIMARY
OSTEOARTHRITIS, RIGHT KNEE 251 6.40%
Total 3,920 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V e r m o n t 95 | P a g e
3) BENEFICIARY DEMOGRAPHICS
Demographics # of Beneficiaries Percent of Beneficiaries
(%)
Sex/Gender
Female 119 55.09%
Male 94 43.52%
Unknown 3 1.39%
Total 216 100.00%
Race
Asian 0 0.00%
Black 1 0.46%
Hispanic 0 0.00%
North American Native 0 0.00%
Other 1 0.46%
Unknown 5 2.31%
White 209 96.76%
Total 216 100.00%
Age
Under 65 26 12.04%
65-70 34 15.74%
71-80 55 25.46%
81-90 79 36.57%
91+ 22 10.19%
Total 216 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V e r m o n t 96 | P a g e
4) PROVIDER REVIEWS SETTINGS
Setting # of Providers Percent of
Providers (%)
0: Acute Care Unit of an Inpatient Facility 6 15.38%
1: Distinct Psychiatric Facility 1 2.56%
2: Distinct Rehabilitation Facility 0 0.00%
3: Distinct Skilled Nursing Facility 21 53.85%
5: Clinic 0 0.00%
6: Distinct Dialysis Center Facility 0 0.00%
7: Dialysis Center Unit of Inpatient Facility 0 0.00%
8: Independent Based RHC 0 0.00%
9: Provider Based RHC 0 0.00%
C: Free Standing Ambulatory Surgery Center 0 0.00%
G: End Stage Renal Disease Unit 1 2.56%
H: Home Health Agency 6 15.38%
N: Critical Access Hospital 3 7.69%
O: Setting Does Not Fit Into Any Other Existing Setting Code 0 0.00%
Q: Long Term Care Facility 0 0.00%
R: Hospice 1 2.56%
S: Psychiatric Unit of an Inpatient Facility 0 0.00%
T: Rehabilitation Unit of an Inpatient Facility 0 0.00%
U: Swing Bed Hospital Designation for Short-Term, Long-Term Care,
and Rehabilitation Hospitals 0 0.00%
Y: Federally Qualified Health Centers 0 0.00%
Z: Swing Bed Designation for Critical Access Hospitals 0 0.00%
Other 0 0.00%
Total 39 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V e r m o n t 97 | P a g e
5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C01: Apparently did not obtain pertinent
history and/or findings from examination 0 0 0.00% 0
C02: Apparently did not make appropriate
diagnoses and/or assessments 2 0 0.00% 1
C03: Apparently did not establish and/or
develop an appropriate treatment plan for a
defined problem or diagnosis which
prompted this episode of care [excludes
laboratory and/or imaging (see C06 or C09)
and procedures (see C07 or C08) and
consultations (see C13 and C14)
5 1 20.00% 1
C04: Apparently did not carry out an
established plan in a competent and/or
timely fashion
1 0 0.00% 0
C05: Apparently did not appropriately
assess and/or act on changes in
clinical/other status results
2 1 50.00% 0
C06: Apparently did not appropriately
assess and/or act on laboratory tests or
imaging study results
0 0 0.00% 0
C07: Apparently did not establish adequate
clinical justification for a procedure which
carries patient risk and was performed
0 0 0.00% 0
C08: Apparently did not perform a
procedure that was indicated (other than lab
and imaging, see C09)
1 0 0.00% 0
C09: Apparently did not obtain appropriate
laboratory tests and/or imaging studies 1 0 0.00% 0
C10: Apparently did not develop and
initiate appropriate discharge, follow-up,
and/or rehabilitation plans
1 0 0.00% 0
C11: Apparently did not demonstrate that
the patient was ready for discharge 1 0 0.00% 0
C12: Apparently did not provide
appropriate personnel and/or resources 0 0 0.00% 0
C13: Apparently did not order appropriate
specialty consultation 2 1 50.00% 0
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V e r m o n t 98 | P a g e
Quality of Care (“C” Category) PRAF
Category Codes
# of
Concerns
# of Concerns
Confirmed
Percent
Confirmed
Concerns
(%)
# of Concerns
Referred as
Quality
Improvement
Initiatives (QII)
C14: Apparently specialty consultation
process was not completed in a timely
manner
0 0 0.00% 0
C15: Apparently did not effectively
coordinate across disciplines 0 0 0.00% 0
C16: Apparently did not ensure a safe
environment (medication errors, falls,
pressure ulcers, transfusion reactions,
nosocomial infection)
1 0 0.00% 0
C17: Apparently did not order/follow
evidence-based practices 0 0 0.00% 0
C18: Apparently did not provide medical
record documentation that impacts patient
care
1 1 100.00% 0
C40: Apparently did not follow up on
patient’s non-compliance 0 0 0.00% 0
C99: Other quality concern not elsewhere
classified 2 0 0.00% 0
Total 20 4 20.00% 2
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V e r m o n t 99 | P a g e
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Review by Notification Type # of Reviews (%) of Total
105: Notice of Non-coverage FFS Preadmission Notice Concurrent
Immediate Review 0 0.00%
106: Notice of Non-coverage FFS Preadmission Notice Non-immediate
Review 0 0.00%
107: Notice of Non-coverage FFS Admission Notice Concurrent
Immediate Review 0 0.00%
108: Notice of Non-coverage FFS Admission Notice Non-immediate
Review 0 0.00%
111: Notice of Non-coverage Request for QIO Concurrence 0 0.00%
117: MA Appeal Review (CORF, HHA, SNF) 0 0.00%
118: FFS Expedited Appeal (CORF, HHA, Hospice, SNF) 0 0.00%
121: Notice of Non-coverage Continued Stay Notice Immediate Review -
Attending Physician Concurs 6 46.15%
122: Notice of Non-coverage Continued Stay Notice Concurrent Non-
immediate Review 4 30.77%
123: Notice of Non-coverage Continued Stay Retrospective 3 23.08%
124: MA Notice of Non-coverage Continued Stay Notice Immediate
Review - Attending Physician Concurs 0 0.00%
Total 13 100.00%
BFCC-QIO 11th
SOW Annual Medical Services Report
08/01/2015 – 07/31/2016
A r e a 1 – V e r m o n t 100 | P a g e
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeals Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Appeal Reviews
Urban 9 24.32% 88.92%
Rural 28 15.68% 10.90%
Unknown 0 0.00% 0.18%
Total 37 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural:
Geographic Area # of Providers
Percent of
Providers in State
(%)
Percent of Providers in
Service Area (%)
Quality of Care Reviews
Urban 2 50.00% 92.84%
Rural 2 50.00% 6.58%
Unknown 0 0.00% 0.58%
Total 4 100.00% 100.00%
8) IMMEDIATE ADVOCACY REVIEWS
# of Beneficiary
Complaints # of Immediate Advocacy Reviews
(%) of Total Beneficiary
Complaints Resolved by
Immediate Advocacy
Immediate Advocacy Reviews
8
2
25.00%
This material was prepared by Livanta LLC, the Medicare Quality Improvement Organization for BFCC Areas 1 and 5, under contract
with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The
contents presented do not necessarily reflect CMS policy. 11SOW-MD-2016-QIOBFCC-CP2