QIO Program
BFCC-QIO 12th SOW Annual Medical Services Review Report Contract Year 1 (June 8 - December 31, 2019) Region 1
BFCC-QIO 12TH SOW ANNUAL MEDICAL
SERVICES REVIEW REPORT
REGION 1
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 2
TABLE OF CONTENTS Introduction: .................................................................................................................................................... 5
Annual Report Body: ........................................................................................................................................ 6
1) Total Number of Reviews ..................................................................................................................... 6
2) Top 10 Principal Medical Diagnoses .................................................................................................... 6
3) Provider Reviews Settings .................................................................................................................... 7
4) Quality of Care Concerns Confirmed and Quality Improvement Initiatives ........................................ 8
5) Discharge/Service Terminations ........................................................................................................... 9
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital
Admissions Outcomes by Notification Type ...................................................................................... 10
7) Evidence Used in Decision-Making ................................................................................................... 11
8) Reviews by Geographic Area ............................................................................................................. 14
9) Outreach and Collaboration with Beneficiaries .................................................................................. 14
10) Immediate Advocacy Cases ................................................................................................................ 15
11) Example/Success Story ....................................................................................................................... 15
12) Beneficiary Helpline Statistics ............................................................................................................ 16
Conclusion: ...................................................................................................................................................... 16
APPENDIX ........................................................................................................................................................... 17
KEPRO BFCC-QIO REGION #1 – State of Connecticut ................................................................................ 17
1) Total Number of Reviews ................................................................................................................... 17
2) Top 10 Principal Medical Diagnoses .................................................................................................. 17
3) Beneficiary Demographics Possible Data Source ............................................................................... 18
4) Provider Reviews Settings .................................................................................................................. 18
5) Quality of Care Concerns Confirmed ................................................................................................. 19
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital
Admissions Outcomes by Notification Type ...................................................................................... 20
7) Reviews by Geographic Area – Urban and Rural ............................................................................... 21
8) Immediate Advocacy Cases ................................................................................................................ 21
KEPRO BFCC-QIO REGION #1 – State of Maine ......................................................................................... 22
1) Total Number of Reviews ................................................................................................................... 22
2) Top 10 Principal Medical Diagnoses .................................................................................................. 22
3) Beneficiary Demographics Possible Data Source ............................................................................... 23
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
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4) Provider Reviews Settings .................................................................................................................. 23
5) Quality of Care Concerns Confirmed ................................................................................................. 24
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital
Admissions Outcomes by Notification Type ...................................................................................... 25
7) Reviews by Geographic Area – Urban and Rural ............................................................................... 26
8) Immediate Advocacy Cases ................................................................................................................ 26
KEPRO BFCC-QIO REGION #1 – State of Massachusetts ............................................................................ 27
1) Total Number of Reviews ................................................................................................................... 27
2) Top 10 Principal Medical Diagnoses .................................................................................................. 27
3) Beneficiary Demographics Possible Data Source ............................................................................... 28
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 ...................................................................................... 30
7) Reviews by Geographic Area – Urban and Rural ............................................................................... 31
8) Immediate Advocacy Cases ................................................................................................................ 31
KEPRO BFCC-QIO REGION #1 – State of New Hampshire ......................................................................... 32
1) Total Number of Reviews ................................................................................................................... 32
2) Top 10 Principal Medical Diagnoses .................................................................................................. 32
3) Beneficiary Demographics Possible Data Source ............................................................................... 33
4) Provider Reviews Settings .................................................................................................................. 33
5) Quality of Care Concerns Confirmed ................................................................................................. 34
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital
Admissions Outcomes by Notification Type ...................................................................................... 35
7) Reviews by Geographic Area – Urban and Rural ............................................................................... 36
8) Immediate Advocacy Cases ................................................................................................................ 36
KEPRO BFCC-QIO REGION #1 – State of Rhode Island .............................................................................. 37
1) Total Number of Reviews ................................................................................................................... 37
2) Top 10 Principal Medical Diagnoses .................................................................................................. 37
3) Beneficiary Demographics Possible Data Source ............................................................................... 38
4) Provider Reviews Settings .................................................................................................................. 38
5) Quality of Care Concerns Confirmed ................................................................................................. 39
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
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6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital
Admissions Outcomes by Notification Type ...................................................................................... 40
7) Reviews by Geographic Area – Urban and Rural ............................................................................... 41
8) Immediate Advocacy Cases ................................................................................................................ 41
KEPRO BFCC-QIO REGION #1 – State of Vermont ..................................................................................... 42
1) Total Number of Reviews ................................................................................................................... 42
2) Top 10 Principal Medical Diagnoses .................................................................................................. 42
3) Beneficiary Demographics Possible Data Source ............................................................................... 43
4) Provider Reviews Settings .................................................................................................................. 43
5) Quality of Care Concerns Confirmed ................................................................................................. 44
6) Beneficiary Appeals of Provider Discharge/Service Terminations and Denials of Hospital
Admissions Outcomes by Notification Type ...................................................................................... 45
7) Reviews by Geographic Area – Urban and Rural ............................................................................... 46
8) Immediate Advocacy Cases ................................................................................................................ 46
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
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INTRODUCTION:
KEPRO is the Centers for Medicare & Medicaid Services
(CMS) designated Beneficiary and Family Centered Care
Quality Improvement Organization (BFCC-QIO) for Region
1, which covers the following states: Connecticut,
Massachusetts, Maine, New Hampshire, Rhode Island, and
Vermont. The Quality Improvement Organization (QIO)
Program is an integral part of the U.S. Department of Health
and Human Services National Quality Strategy and the CMS
Quality Strategy. Within this report, you will find data which
reflects the work KEPRO has completed within the first year
of its BFCC-QIO contract. The first section of this report contains global data followed by an Appendix with
state-specific data.
The QIO Program is all about improving the quality, safety, and value of the care the Medicare beneficiary
receives through the Medicare program. 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, such as KEPRO, review complaints about the quality of medical care. They also provide an
appeal process for Medicare beneficiaries when a healthcare provider wants to discontinue services or discharge
the beneficiary from the hospital. KEPRO provides a service called Immediate Advocacy for beneficiaries who
want to quickly resolve a Medicare situation with a provider, which does not require a medical record review.
By providing these services, the rights of Medicare beneficiaries are protected while also protecting the
Medicare Trust Fund.
Region 1
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
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ANNUAL REPORT BODY:
1) TOTAL NUMBER OF REVIEWS
The data below reflects the total number of medical record reviews completed for Region 1.
The BFCC-QIO has review authority for a number of different situations. These include:
• Beneficiaries or their appointed representatives who have concerns related to the quality of provided
healthcare services by either a facility or physician.
• Beneficiaries or their representatives who are appealing a pending hospital discharge or the
discontinuation of skilled services such as physical therapy.
• Potential Emergency Medical Treatment & Labor Act (EMTALA) violations – In 1986, Congress
enacted EMTALA to ensure public access to emergency services regardless of ability to pay. Section
1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that
offer emergency services to provide a medical screening examination (MSE) when a request is made for
examination or treatment for an emergency medical condition (EMC), including active labor, regardless
of an individual's ability to pay. Hospitals are then required to provide stabilizing treatment for patients
with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an
appropriate transfer should be implemented.
Review Type
Number of
Reviews
Percent of
Total Reviews
Quality of Care Review (Beneficiary Complaint) 45 1.24%
Quality of Care Review (All Other Selection Reasons) 4 0.11%
Notice of Non-coverage (Admission and Preadmission, HINN 1) 50 1.38%
Notice of Non-coverage (BIPA) 1,347 37.25%
Notice of Non-coverage (Grijalva) 1,532 42.37%
Notice of Non-coverage (Weichardt) 631 17.45%
Notice of Non-coverage (Request for QIO Concurrence/HINN 10) 3 0.08%
Emergency Medical Treatment & Labor Act (EMTALA) 5 Day 3 0.08%
EMTALA 60 Day 1 0.03%
Total 3,616 100.00%
2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses
Number of
Beneficiaries
Percent of
Beneficiaries
1. A419 - SEPSIS, UNSPECIFIED ORGANISM 18,373 27.69%
2. I130 - HYP HRT & CHR KDNY DIS W HRT FAIL AND STG 1-
4/UNSP CHR KDNY 7,666 11.55%
3. I110 - HYPERTENSIVE HEART DISEASE WITH HEART FAILURE 6,610 9.96%
4. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 6,221 9.38%
5. N390 - URINARY TRACT INFECTION, SITE NOT SPECIFIED 5,178 7.80%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
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Top 10 Medical Diagnoses
Number of
Beneficiaries
Percent of
Beneficiaries
6. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W
(ACUTE) EXACERBATION 5,072 7.64%
7. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL
INFARCTION 4,969 7.49%
8. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 4,932 7.43%
9. M1711 - UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT
KNEE 3,705 5.58%
10. J690 - PNEUMONITIS DUE TO INHALATION OF FOOD AND
VOMIT 3,623 5.46%
Total 66,349 100.00%
3) PROVIDER REVIEWS SETTINGS
Setting
Number of
Providers
Percent of
Providers
0: Acute Care Unit of an Inpatient Facility 109 14.53%
1: Distinct Psychiatric Facility 5 0.67%
2: Distinct Rehabilitation Facility 9 1.20%
3: Distinct Skilled Nursing Facility 539 71.87%
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 Rural Health Clinic (RHC) 0 0.00%
9: Provider Based Rural Health Clinic (RHC) 0 0.00%
C: Free Standing Ambulatory Surgery Center 0 0.00%
G: End Stage Renal Disease Unit 1 0.13%
H: Home Health Agency 36 4.80%
N: Critical Access Hospital 8 1.07%
O: Setting does not fit into any other existing setting code 0 0.00%
Q: Long-Term Care Facility 8 1.07%
R: Hospice 28 3.73%
S: Psychiatric Unit of an Inpatient Facility 3 0.40%
T: Rehabilitation Unit of an Inpatient Facility 1 0.13%
U: Swing Bed Hospital Designation for Short-Term, Long-Term Care, and
Rehabilitation Hospitals 0 0.00%
Y: Federally Qualified Health Centers 1 0.13%
Z: Swing Bed Designation for Critical Access Hospitals 2 0.27%
Other 0 0.00%
Total 750 100.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
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4) QUALITY OF CARE CONCERNS CONFIRMED AND QUALITY IMPROVEMENT INITIATIVES
4.a. QUALITY OF CARE CONCERNS CONFIRMED
The below data reflects the category of quality of care concerns identified during medical record reviews along
with the corresponding outcome.
A Quality of Care review is conducted by the BFCC-QIO to determine whether the quality of services provided
to beneficiaries was consistent with professionally recognized standards of health care. A Quality of Care
review can either be initiated by a Medicare beneficiary or his/her appointed representative or referred to the
BFCC-QIO from another agency such as the Office of Medicare Ombudsmen and/or Congress, etc.
Quality of Care (“C” Category) PRAF Category Codes
Number of
Concerns
Number of
Concerns
Confirmed
Percent
Confirmed
Concerns
C01: Apparently did not obtain pertinent history and/or findings from
examination 1 0 0.00%
C02: Apparently did not make appropriate diagnoses and/or
assessments 18 0 0.00%
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),
procedures (see C07 or C08) and consultations (see C13 and C14)]
32 2 6.25%
C04: Apparently did not carry out an established plan in a competent
and/or timely fashion 13 3 23.08%
C05: Apparently did not appropriately assess and/or act on changes in
clinical/other status results 2 0 0.00%
C06: Apparently did not appropriately assess and/or act on laboratory
tests or imaging study results 1 0 0.00%
C07: Apparently did not establish adequate clinical justification for a
procedure which carries patient risk and was performed 0 0 0.00%
C08: Apparently did not perform a procedure that was indicated (other
than lab and imaging, see C09) 4 0 0.00%
C09: Apparently did not obtain appropriate laboratory tests and/or
imaging studies 2 0 0.00%
C10: Apparently did not develop and initiate appropriate discharge,
follow-up, and/or rehabilitation plans 5 0 0.00%
C11: Apparently did not demonstrate that the patient was ready for
discharge 11 0 0.00%
C12: Apparently did not provide appropriate personnel and/or resources 1 0 0.00%
C13: Apparently did not order appropriate specialty consultation 3 1 33.33%
C14: Apparently specialty consultation process was not completed in a
timely manner 0 0 0.00%
C15: Apparently did not effectively coordinate across disciplines 0 0 0.00%
C16: Apparently did not ensure a safe environment (medication errors,
falls, pressure ulcers, transfusion reactions, nosocomial infection) 6 1 16.67%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
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Quality of Care (“C” Category) PRAF Category Codes
Number of
Concerns
Number of
Concerns
Confirmed
Percent
Confirmed
Concerns
C17: Apparently did not order/follow evidence-based practices 1 0 0.00%
C18: Apparently did not provide medical record documentation that
impacts patient care 0 0 0.00%
C40: Apparently did not follow up on patient’s non-compliance 0 0 0.00%
C99: Other quality concern not elsewhere classified 5 0 0.00%
Total 105 7 6.67%
4.b. QUALITY IMPROVEMENT INITIATIVES (QII)
QII data is not included in the Contract Year 1 (CY1) BFCC-QIO 12th SOW Annual Medical Services Review
Report. QII referrals were paused during the date range in this report due to the procurement process and
transition from 11th to 12th Statement of Work.
5) DISCHARGE/SERVICE TERMINATIONS
The data below reflects the discharge location of beneficiaries linked to discharge/service termination reviews
for Request for BFCC-QIO Concurrence and Weichardt Reviews completed in Region 1. Please note that the
discharge location data for the completed appeals reported may be incomplete because of the inability to link
them from the claims data.
Note: Data contained in this table represent discharge/service termination reviews from June 8, 2019, to
December 31, 2019. A shortened time frame is necessary to allow for maturity of claims data, which are the
source of “Discharge Status” for these cases.
Discharge Status
Number of
Beneficiaries
Percent of
Beneficiaries
01: Discharged to home or self care (routine discharge) 3 27.27%
02: Discharged/transferred to another short-term general hospital for inpatient
care 0 0.00%
03: Discharged/transferred to skilled nursing facility (SNF) 6 54.55%
04: Discharged/transferred to intermediate care facility (ICF) 0 0.00%
05: Discharged/transferred to another type of institution (including distinct parts) 0 0.00%
06: Discharged/transferred to home under care of organized home health service
organization 1 9.09%
07: Left against medical advice or discontinued care 0 0.00%
09: Admitted as an inpatient to this hospital 0 0.00%
20: Expired (or did not recover – Christian Science patient) 0 0.00%
21: Discharged/transferred to court/law enforcement 0 0.00%
30: Still a patient 0 0.00%
40: Expired at home (Hospice claims only) 0 0.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
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Discharge Status
Number of
Beneficiaries
Percent of
Beneficiaries
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 0 0.00%
50: Hospice - home 1 9.09%
51: Hospice - medical facility 0 0.00%
61: Discharged/transferred within this institution to a hospital-based, Medicare-
approved swing bed 0 0.00%
62: Discharged/transferred to an inpatient rehabilitation facility including
distinct part units of a hospital 0 0.00%
63: Discharged/transferred to a long-term care hospital 0 0.00%
64: Discharged/transferred to a nursing facility certified under Medicaid but not
under Medicare 0 0.00%
65: Discharged/transferred to a psychiatric hospital or psychiatric distinct part
unit of a hospital 0 0.00%
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 0 0.00%
Other 0 0.00%
Total 11 100.00%
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
The data below reflect the number of appeal reviews and the percentage of reviews, for each outcome, in which
the physician reviewer either agreed or disagreed with the hospital discharge or discontinuation of skilled
services decision.
Appeal Review by Notification Type
Number
of
Reviews
Physician
Reviewer
Disagreed with
Discharge (%)
Physician
Reviewer
Agreed with
Discharge (%)
Notice of Non-coverage FFS Preadmission/Admission -
(Admission and Preadmission/HINN 1) 46 32.61% 67.39%
Notice of Non-coverage Request for BFCC-QIO Concurrence -
(Request for BFCC-QIO Concurrence/HINN 10) 3 33.33% 66.67%
MA Appeal Review (CORF, HHA, SNF) – (Grijalva) 1,292 34.98% 65.02%
FFS Expedited Appeal (CORF, HHA, Hospice, SNF) – (BIPA) 1,251 22.54% 77.46%
Notice of Non-coverage Hospital Discharge Notice - Attending
Physician Concurs - (FFS Weichardt) 469 6.40% 93.60%
MA Notice of Non-coverage Hospital Discharge Notice -
Attending Physician Concurs - (MA Weichardt) 120 8.33% 91.67%
Total 3,181 24.83% 75.17%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 11
7) EVIDENCE USED IN DECISION-MAKING
The table that follows describes the most common types of evidence or standards of care used to support
KEPRO Review Analysts’ assessments, which aid in formatting questions raised to the Peer Reviewer for
his/her clinical decisions for medical necessity/utilization review and appeals.
For the Quality of Care reviews, KEPRO has provided one to three of the most highly utilized types of
evidence/standards of care to support KEPRO Review Analysts’ assessments, which aid in formatting questions
raised to the Peer Reviewer for his/her clinical decisions. 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 CMS’ Pneumonia
indicators (PN 2-7)
UpToDate®
CMS’ guidelines for the management of
patients with Community Acquired
Pneumonia (CAP) address basic aspects
of preventive care and treatment. The
guidelines emphasize the importance of
vaccination as well as the need for
appropriate and timely antimicrobial
therapy. Adherence to guidelines is
associated with improved patient
outcomes.
UpToDate® is the premier evidence-
based clinical decision support resource,
trusted worldwide by healthcare
practitioners to help them make the right
decisions at the point of care. It is proven
to change the way clinicians practice
medicine and is the only resource of its
kind associated with improved
outcomes.
Heart Failure American College of
Cardiology (ACC);
CMS’ Heart Failure
indicators (HF 1-3)
UpToDate®
ACC’s guidelines for the management of
patients with heart failure address
aspects of care that when followed are
associated with improved patient
outcomes.
UpToDate® is the premier evidence-
based clinical decision support resource,
trusted worldwide by healthcare
practitioners to help them make the right
decisions at the point of care. It is proven
to change the way clinicians practice
medicine and is the only resource of its
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 12
kind associated with improved
outcomes.
Pressure Ulcers AHRQ website;
Wound, Ostomy &
Continence Nursing
website
(www.WOCN.org)
CMS’ Hospital
Acquired Conditions
& Patient Safety
Indicators (PSI-03 &
PSI-90 Composite
Measure)
UpToDate®
The Agency for Healthcare Research and
Quality (AHRQ) remains an excellent
online resource for the identification of
standards of care and practice guidelines.
WOCN provides nursing guidelines for
staging and care of pressure ulcers.
CMS’ Patient Safety Indicators (PSI) are
measurements of quality of patient care
during hospitalization and were
developed by AHRQ after years of
research and analysis. AHRQ developed
the PSIs to help hospitals identify
potentially preventable adverse events or
serious medical errors.
UpToDate® is the premier evidence-
based clinical decision support resource,
trusted worldwide by healthcare
practitioners to help them make the right
decisions at the point of care. It is proven
to change the way clinicians practice
medicine and is the only resource of its
kind associated with improved
outcomes.
Acute Myocardial
Infarction
American College of
Cardiology (ACC)
Acute Myocardial
Infarction
Guidelines; CMS’
Acute Myocardial
Infarction indicators
(AMI 2-10)
UpToDate®
ACC’s guidelines for the management of
patients with acute myocardial infarction
address aspects of care that when
followed are associated with improved
patient outcomes.
UpToDate® is the premier evidence-
based clinical decision support resource,
trusted worldwide by healthcare
practitioners to help them make the right
decisions at the point of care. It is proven
to change the way clinicians practice
medicine and is the only resource of its
kind associated with improved
outcomes.
Urinary Tract
Infection
HAI-CAUTI (f/k/a
HAC-7)
UpToDate®
CMS’ PSIs are measurements of quality
of patient care during hospitalization and
were developed by AHRQ after years of
research and analysis. AHRQ developed
the PSIs to help hospitals identify
potentially preventable adverse events or
serious medical errors.
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 13
UpToDate® is the premier evidence-
based clinical decision support resource,
trusted worldwide by healthcare
practitioners to help them make the right
decisions at the point of care. It is proven
to change the way clinicians practice
medicine and is the only resource of its
kind associated with improved
outcomes.
Sepsis Institute for
Healthcare
Improvement (IHI)
UpToDate®
IHI developed sepsis indicators and
guidelines for the identification and
treatment of sepsis. Adherence to such
guidelines has improved patient
outcomes.
UpToDate® is the premier evidence-
based clinical decision support resource,
trusted worldwide by healthcare
practitioners to help them make the right
decisions at the point of care. It is proven
to change the way clinicians practice
medicine and is the only resource of its
kind associated with improved
outcomes.
Adverse Drug
Events
CMS’ Hospital
Acquired Conditions
& Patient Safety
Indicators (PSI-03 &
PSI-90 Composite
Measure)
CMS’ PSIs are measurements of quality
of patient care during hospitalization and
were developed by AHRQ after years of
research and analysis. AHRQ developed
the PSIs to help hospitals identify
potentially preventable adverse events or
serious medical errors.
Falls CMS’ Hospital
Acquired Conditions
& Patient Safety
Indicators (PSI-03 &
PSI-90 Composite
Measure)
CMS’ PSIs are measurements of quality
of patient care during hospitalization and
were developed by AHRQ after years of
research and analysis. AHRQ developed
the PSIs to help hospitals identify
potentially preventable adverse events or
serious medical errors.
Patient Trauma CMS’ Hospital
Acquired Conditions
& Patient Safety
Indicators (PSI-03 &
PSI-90 Composite
Measure)
CMS’ PSIs are measurements of quality
of patient care during hospitalization and
were developed by AHRQ after years of
research and analysis. AHRQ developed
the PSIs to help hospitals identify
potentially preventable adverse events or
serious medical errors.
Surgical
Complications
Surgical
complications
KEPRO’s Generic Quality Screening
Tool
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 14
8) REVIEWS BY GEOGRAPHIC AREA
In tables 8A-B, KEPRO has provided the count and percent by rural vs. urban geographical locations for Health
Service Providers (HSPs) associated with a completed BFCC-QIO review.
Table 8A: Appeal Reviews by Geographic Area – Urban and Rural
Geographic Area Number of Providers Percent of Providers in Service Area
Urban 662 90.56%
Rural 65 8.89%
Unknown 4 0.55%
Total 731 100.00%
Table 8B: Quality of Care Reviews by Geographic Area – Urban and Rural
Geographic Area Number of Providers Percent of Providers in Service Area
Urban 26 92.86%
Rural 2 7.14%
Unknown 0 0.00%
Total 28 100.00%
9) OUTREACH AND COLLABORATION WITH BENEFICIARIES
KEPRO developed a collaborative partnership with the Massachusetts Senior Medicare Patrol (SMP) program,
which empowers Medicare beneficiaries and their families to become engaged healthcare consumers. The MA
SMP program conducted approximately 50 outreach and education events, reaching more than 8,000 Medicare
beneficiaries. Information about KEPRO’s services was included in the MA SMP program’s “Gaining Access”
flyer, a comprehensive resource guide for the 1.3 million Medicare beneficiaries in Massachusetts. A
presentation was also done at the MA SMP Case Management meeting, where information about KEPRO was
shared with case managers throughout the state.
Appeals National Coverage
Determination
Guidelines; JIMMO
settlement language
and guidelines,
InterQual®, and
CMS’ Two Midnight
Rule Benchmark
criteria
Determination Guidelines; JIMMO
settlement language and guidelines,
InterQual®, and CMS’ Two Midnight
Rule Benchmark criteria
Medicare coverage is limited to items
and services that are reasonable and
necessary for the diagnosis or treatment
of an illness or injury (and within the
scope of a Medicare benefit category).
National coverage determinations
(NCDs) are made through an evidence-
based process.
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
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KEPRO also developed a valuable partnership with the New Hampshire Hospital Association. At the start of the
12th SOW, KEPRO presented to the New Hampshire Hospital Association and shared information about the
BFCC-QIO’s services and addressed questions to help smooth the contract transition and establish a good
rapport with providers across the state. KEPRO has maintained a relationship with this stakeholder, sharing
important updates and information about services as well as providing the hospital association with educational
materials. KEPRO’s information and materials are shared with the 30 registered hospitals that are a part of the
New Hampshire Hospital Association serving the state’s 295,000 Medicare beneficiaries.
10) IMMEDIATE ADVOCACY CASES
The data below reflects the number of beneficiary complaints resolved through the use of Immediate Advocacy.
Based on the nature of the concern(s) raised by the beneficiary, KEPRO staff members may recommend the use
of Immediate Advocacy. Immediate Advocacy (IA) is an informal process used by KEPRO to quickly resolve
an oral complaint about medical care or services. It involves KEPRO contacting a practitioner, healthcare
provider, or facility on behalf of the beneficiary. Some of the benefits of the IA process include resolving
complaints that are not right for a medical record review, improved satisfaction for the Medicare beneficiary
and the provider, and a quicker time to resolve the concern.
Number of
Beneficiary Complaints
Number of Immediate
Advocacy Cases
Percent of Total Beneficiary
Complaints Resolved by Immediate
Advocacy
116 84 72.41%
11) EXAMPLE/SUCCESS STORY
A Medicare beneficiary contacted KEPRO with concerns about his follow-up care after surgery. He was in pain
after surgery on his right foot, and the doctors that performed the surgery would not see him for follow-up care.
He was on an IV due to an infection in his foot and requested an intervention by KEPRO.
KEPRO’s Clinical Care Coordinator (CCC) contacted the case manager at the hospital where the surgery was
performed, to advocate for the beneficiary’s proper treatment and follow-up care. The case manager stated that
the wound doctor did not want to do follow-up with the beneficiary, due to his noncompliance. She stated that
she would contact another wound care physician for the follow-up care and the foot pain issue and that she was
also handling the IV situation. The CCC called the beneficiary to let him know that the hospital case manager
would be addressing his concerns. He stated that he was satisfied with the intervention.
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 16
12) BENEFICIARY HELPLINE STATISTICS
Beneficiary Helpline Report Total Per Category
Total Number of Calls Received 33,982
Total Number of Calls Answered 24,758
Total Number of Abandoned Calls 4,510
Average Length of Call Wait Times* 00:04:51 (291 Secs)
Number of Calls Transferred by 1-800-Medicare 287
* In the time frame from June 9 – December 31, 2019, KEPRO’s Average Length of Call Wait Times was
directly impacted by the transition from its proprietary appeal system to the CMS designated Case Review
System – QMARS. KEPRO followed CMS’ instructions and in June/July 2019 experienced a very difficult time
working within the QMARS application and subsequently reverted back to our internal appeals system mid-
July. The difficulties experienced included tripling the amount of time required to initiate an appeal – increasing
from approximately 15 minutes in KEPRO’s internal system to as much as 45 minutes in CMS’ QMARS
application. This increase in processing time increased the overall number of inbound calls, increased wait
times, increased the number of voice mail messages that were left and required processing, and resulted in
decreased satisfaction with KEPRO’s handling of calls.
In mid-July, KEPRO returned to using its proprietary appeal system, and by mid-August, our call center volume
returned to industry standard benchmarks. Call wait times were less than two minutes, abandonment rate was
less than 5%, and the percentage of calls answered with 30 seconds was 85%.
CONCLUSION:
KEPRO’s outcomes and findings for year one of this CMS contract outline the daily work performed during the
pursuit of care improvements provided to the individual Medicare beneficiary. These reviews provide solid data
that can be extrapolated to improve the quality of provider care throughout the system based upon these
individual’s experiences.
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 17
APPENDIX
KEPRO BFCC-QIO REGION #1 – STATE OF CONNECTICUT
1) TOTAL NUMBER OF REVIEWS
Review Type
Number of
Reviews
Percent of
Total Reviews
Quality of Care Review (Beneficiary Complaint) 9 0.62%
Quality of Care Review (All Other Selection Reasons) 1 0.07%
Notice of Non-coverage (Admission and Preadmission/HINN 1) 2 0.14%
Notice of Non-coverage (BIPA) 515 35.52%
Notice of Non-coverage (Grijalva) 764 52.69%
Notice of Non-coverage (Weichardt) 159 10.97%
Notice of Non-coverage (Request for QIO Concurrence/HINN 10) 0 0.00%
EMTALA 5 Day 0 0.00%
EMTALA 60 Day 0 0.00%
Total 1,450 100.00%
2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses
Number of
Beneficiaries
Percent of
Beneficiaries
1. A419 - SEPSIS, UNSPECIFIED ORGANISM 4,604 32.94%
2. I130 - HYP HRT & CHR KDNY DIS W HRT FAIL AND STG
1-4/UNSP CHR KDNY 1,552 11.11%
3. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 1,489 10.65%
4. I110 - HYPERTENSIVE HEART DISEASE WITH HEART
FAILURE 1,358 9.72%
5. N390 - URINARY TRACT INFECTION, SITE NOT SPECIFIED 1,043 7.46%
6. M1711 - UNILATERAL PRIMARY OSTEOARTHRITIS,
RIGHT KNEE 831 5.95%
7. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 830 5.94%
8. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL
INFARCTION 781 5.59%
9. M1712 - UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT
KNEE 744 5.32%
10. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W
(ACUTE) EXACERBATION 743 5.32%
Total 13,975 100.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 18
3) BENEFICIARY DEMOGRAPHICS POSSIBLE DATA SOURCE
Demographics Number of Beneficiaries Percent of Beneficiaries
Sex/Gender
Female 880 61.37%
Male 554 38.63%
Unknown 0 0.00%
Total 1,434 100.00%
Race
Asian 9 0.63%
Black 124 8.65%
Hispanic 10 0.70%
North American Native 0 0.00%
Other 10 0.70%
Unknown 26 1.81%
White 1,255 87.52%
Total 1,434 100.00%
Age
Under 65 103 7.18%
65-70 150 10.46%
71-80 418 29.15%
81-90 543 37.87%
91+ 220 15.34%
Total 1,434 100.00%
4) PROVIDER REVIEWS SETTINGS
Setting
Number of
Providers
Percent of
Providers
0: Acute Care Unit of an Inpatient Facility 22 10.58%
1: Distinct Psychiatric Facility 0 0.00%
2: Distinct Rehabilitation Facility 1 0.48%
3: Distinct Skilled Nursing Facility 160 76.92%
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 Rural Health Clinic (RHC) 0 0.00%
9: Provider Based Rural Health Clinic (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 14 6.73%
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 3 1.44%
R: Hospice 7 3.37%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 19
Setting
Number of
Providers
Percent of
Providers
S: Psychiatric Unit of an Inpatient Facility 1 0.48%
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 208 100.00%
5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF Category Codes
Number
of
Concerns
Number of
Concerns
Confirmed
Percent
Confirmed
Concerns
C01: Apparently did not obtain pertinent history and/or findings from
examination 0 0 0.00%
C02: Apparently did not make appropriate diagnoses and/or assessments 4 0 0.00%
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)]
7 1 14.29%
C04: Apparently did not carry out an established plan in a competent
and/or timely fashion 8 1 12.50%
C05: Apparently did not appropriately assess and/or act on changes in
clinical/other status results 1 0 0.00%
C06: Apparently did not appropriately assess and/or act on laboratory
tests or imaging study results 0 0 0.00%
C07: Apparently did not establish adequate clinical justification for a
procedure which carries patient risk and was performed 0 0 0.00%
C08: Apparently did not perform a procedure that was indicated (other
than lab and imaging, see C09) 0 0 0.00%
C09: Apparently did not obtain appropriate laboratory tests and/or
imaging studies 1 0 0.00%
C10: Apparently did not develop and initiate appropriate discharge,
follow-up, and/or rehabilitation plans 3 0 0.00%
C11: Apparently did not demonstrate that the patient was ready for
discharge 3 0 0.00%
C12: Apparently did not provide appropriate personnel and/or resources 1 0 0.00%
C13: Apparently did not order appropriate specialty consultation 1 1 100.00%
C14: Apparently specialty consultation process was not completed in a
timely manner 0 0 0.00%
C15: Apparently did not effectively coordinate across disciplines 0 0 0.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 20
Quality of Care (“C” Category) PRAF Category Codes
Number
of
Concerns
Number of
Concerns
Confirmed
Percent
Confirmed
Concerns
C16: Apparently did not ensure a safe environment (medication errors,
falls, pressure ulcers, transfusion reactions, nosocomial infection) 2 1 50.00%
C17: Apparently did not order/follow evidence-based practices 0 0 0.00%
C18: Apparently did not provide medical record documentation that
impacts patient care 0 0 0.00%
C40: Apparently did not follow up on patient’s non-compliance 0 0 0.00%
C99: Other quality concern not elsewhere classified 1 0 0.00%
Total 32 4 12.50%
*QII data is not included in the Contract Year 1 (CY1) BFCC-QIO 12th SOW Annual Medical Services Review
Report. QII referrals were paused during the date range in this report due to procurement process and
transition from 11th to 12th Statement of Work.
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Reviews by Notification Type
Number of
Reviews
Percent
of Total
Notice of Non-coverage FFS Preadmission/Admission Notice - (Admission and
Preadmission/HINN 1) 2 0.16%
Notice of Non-coverage Request for BFCC-QIO Concurrence - (Request for BFCC-
QIO Concurrence/HINN 10) 0 0.00%
MA Appeal Review (CORF, HHA, SNF) - (Grijalva) 651 51.02%
FFS Expedited Appeal (CORF, HHA, Hospice, SNF) - (BIPA) 480 37.62%
Notice of Non-coverage Hospital Discharge Notice - Attending Physician Concurs -
(FFS Weichardt) 107 8.39%
MA Notice of Non-coverage Hospital Discharge Notice - Attending Physician Concurs
- (MA Weichardt) 36 2.82%
Total 1,276 100.00%
Quality of Care Concerns Referred for Quality Improvement Initiatives (QIIs)
Number of Concerns Referred for QII Percent of Quality of Care Concerns
Referred for QII
N/A* N/A*
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 21
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeal Reviews by Geographic Area – Urban and Rural
Geographic Area Number of Providers
Percent of
Providers in State
Percent of Providers in
Service Area
Urban 194 94.63% 90.56%
Rural 9 4.39% 8.89%
Unknown 2 0.98% 0.55%
Total 205 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural
Geographic Area Number of Providers
Percent of
Providers in State
Percent of Providers in
Service Area
Urban 8 100.00% 92.86%
Rural 0 0.00% 7.14%
Unknown 0 0.00% 0.00%
Total 8 100.00% 100.00%
8) IMMEDIATE ADVOCACY CASES
Number of Beneficiary
Complaints
Number of Immediate
Advocacy Cases
Percent of Total Beneficiary Complaints
Resolved by Immediate Advocacy
27 21 77.78%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 22
KEPRO BFCC-QIO REGION #1 – STATE OF MAINE
1) TOTAL NUMBER OF REVIEWS
Review Type
Number of
Reviews
Percent of
Total Reviews
Quality of Care Review (Beneficiary Complaint) 2 0.85%
Quality of Care Review (All Other Selection Reasons) 0 0.00%
Notice of Non-coverage (Admission and Preadmission/HINN 1) 11 4.66%
Notice of Non-coverage (BIPA) 52 22.03%
Notice of Non-coverage (Grijalva) 103 43.64%
Notice of Non-coverage (Weichardt) 66 27.97%
Notice of Non-coverage (Request for QIO Concurrence/HINN 10) 1 0.42%
EMTALA 5 Day 1 0.42%
EMTALA 60 Day 0 0.00%
Total 236 100.00%
2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses
Number of
Beneficiaries
Percent of
Beneficiaries
1. A419 - SEPSIS, UNSPECIFIED ORGANISM 1,758 29.94%
2. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL
INFARCTION 682 11.61%
3. I130 - HYP HRT & CHR KDNY DIS W HRT FAIL AND STG 1-
4/UNSP CHR KDNY 650 11.07%
4. I110 - HYPERTENSIVE HEART DISEASE WITH HEART FAILURE 495 8.43%
5. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W
(ACUTE) EXACERBATION 453 7.71%
6. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 437 7.44%
7. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 436 7.43%
8. N390 - URINARY TRACT INFECTION, SITE NOT SPECIFIED 354 6.03%
9. J690 - PNEUMONITIS DUE TO INHALATION OF FOOD AND
VOMIT 326 5.55%
10. M1612 - UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT HIP 281 4.79%
Total 5,872 100.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 23
3) BENEFICIARY DEMOGRAPHICS POSSIBLE DATA SOURCE
Demographics Number of Beneficiaries Percent of Beneficiaries
Sex/Gender
Female 145 57.31%
Male 108 42.69%
Unknown 0 0.00%
Total 253 100.00%
Race
Asian 0 0.00%
Black 5 1.98%
Hispanic 0 0.00%
North American Native 0 0.00%
Other 0 0.00%
Unknown 3 1.19%
White 245 96.84%
Total 253 100.00%
Age
Under 65 37 14.62%
65-70 39 15.42%
71-80 66 26.09%
81-90 86 33.99%
91+ 25 9.88%
Total 253 100.00%
4) PROVIDER REVIEWS SETTINGS
Setting
Number of
Providers
Percent of
Providers
0: Acute Care Unit of an Inpatient Facility 12 18.46%
1: Distinct Psychiatric Facility 0 0.00%
2: Distinct Rehabilitation Facility 1 1.54%
3: Distinct Skilled Nursing Facility 47 72.31%
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 Rural Health Clinic (RHC) 0 0.00%
9: Provider Based Rural Health Clinic (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 2 3.08%
N: Critical Access Hospital 2 3.08%
O: Setting does not fit into any other existing setting code 0 0.00%
Q: Long-Term Care Facility 0 0.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 24
Setting
Number of
Providers
Percent of
Providers
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 1 1.54%
Other 0 0.00%
Total 65 100.00%
5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF Category Codes
Number
of
Concerns
Number of
Concerns
Confirmed
Percent
Confirmed
Concerns
C01: Apparently did not obtain pertinent history and/or findings from
examination 0 0 0.00%
C02: Apparently did not make appropriate diagnoses and/or assessments 0 0 0.00%
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)]
1 0 0.00%
C04: Apparently did not carry out an established plan in a competent
and/or timely fashion 0 0 0.00%
C05: Apparently did not appropriately assess and/or act on changes in
clinical/other status results 0 0 0.00%
C06: Apparently did not appropriately assess and/or act on laboratory
tests or imaging study results 0 0 0.00%
C07: Apparently did not establish adequate clinical justification for a
procedure which carries patient risk and was performed 0 0 0.00%
C08: Apparently did not perform a procedure that was indicated (other
than lab and imaging, see C09) 0 0 0.00%
C09: Apparently did not obtain appropriate laboratory tests and/or
imaging studies 0 0 0.00%
C10: Apparently did not develop and initiate appropriate discharge,
follow-up, and/or rehabilitation plans 0 0 0.00%
C11: Apparently did not demonstrate that the patient was ready for
discharge 4 0 0.00%
C12: Apparently did not provide appropriate personnel and/or resources 0 0 0.00%
C13: Apparently did not order appropriate specialty consultation 0 0 0.00%
C14: Apparently specialty consultation process was not completed in a
timely manner 0 0 0.00%
C15: Apparently did not effectively coordinate across disciplines 0 0 0.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 25
Quality of Care (“C” Category) PRAF Category Codes
Number
of
Concerns
Number of
Concerns
Confirmed
Percent
Confirmed
Concerns
C16: Apparently did not ensure a safe environment (medication errors,
falls, pressure ulcers, transfusion reactions, nosocomial infection) 1 0 0.00%
C17: Apparently did not order/follow evidence-based practices 0 0 0.00%
C18: Apparently did not provide medical record documentation that
impacts patient care 0 0 0.00%
C40: Apparently did not follow up on patient’s non-compliance 0 0 0.00%
C99: Other quality concern not elsewhere classified 0 0 0.00%
Total 6 0 0.00%
*QII data is not included in the Contract Year 1 (CY1) BFCC-QIO 12th SOW Annual Medical Services Review
Report. QII referrals were paused during the date range in this report due to procurement process and
transition from 11th to 12th Statement of Work.
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Reviews by Notification Type
Number of
Reviews
Percent
of Total
Notice of Non-coverage FFS Preadmission/Admission Notice - (Admission and
Preadmission/HINN 1) 9 4.33%
Notice of Non-coverage Request for BFCC-QIO Concurrence - (Request for BFCC-
QIO Concurrence/HINN 10) 1 0.48%
MA Appeal Review (CORF, HHA, SNF) - (Grijalva) 92 44.23%
FFS Expedited Appeal (CORF, HHA, Hospice, SNF) - (BIPA) 44 21.15%
Notice of Non-coverage Hospital Discharge Notice - Attending Physician Concurs -
(FFS Weichardt) 53 25.48%
MA Notice of Non-coverage Hospital Discharge Notice - Attending Physician Concurs
- (MA Weichardt) 9 4.33%
Total 208 100.00%
Quality of Care Concerns Referred for Quality Improvement Initiatives (QIIs)
Number of Concerns Referred for QII Percent of Quality of Care Concerns
Referred for QII
N/A* N/A*
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 26
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeal Reviews by Geographic Area – Urban and Rural
Geographic Area Number of Providers
Percent of
Providers in State
Percent of Providers in
Service Area
Urban 39 60.94% 90.56%
Rural 24 37.50% 8.89%
Unknown 1 1.56% 0.55%
Total 64 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural
Geographic Area Number of Providers
Percent of
Providers in State
Percent of Providers in
Service Area
Urban 1 50.00% 92.86%
Rural 1 50.00% 7.14%
Unknown 0 0.00% 0.00%
Total 2 100.00% 100.00%
8) IMMEDIATE ADVOCACY CASES
Number of Beneficiary
Complaints
Number of Immediate
Advocacy Cases
Percent of Total Beneficiary Complaints
Resolved by Immediate Advocacy
6 4 66.67%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 27
KEPRO BFCC-QIO REGION #1 – STATE OF MASSACHUSETTS
1) TOTAL NUMBER OF REVIEWS
Review Type
Number of
Reviews
Percent of
Total Reviews
Quality of Care Review (Beneficiary Complaint) 24 2.01%
Quality of Care Review (All Other Selection Reasons) 2 0.17%
Notice of Non-coverage (Admission and Preadmission/HINN 1) 21 1.76%
Notice of Non-coverage (BIPA) 598 50.08%
Notice of Non-coverage (Grijalva) 349 29.23%
Notice of Non-coverage (Weichardt) 197 16.50%
Notice of Non-coverage (Request for QIO Concurrence/HINN 10) 1 0.08%
EMTALA 5 Day 1 0.08%
EMTALA 60 Day 1 0.08%
Total 1,194 100.00%
2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses
Number of
Beneficiaries
Percent of
Beneficiaries
1. A419 - SEPSIS, UNSPECIFIED ORGANISM 8,502 25.70%
2. I130 - HYP HRT & CHR KDNY DIS W HRT FAIL AND STG 1-
4/UNSP CHR KDNY 3,988 12.05%
3. I110 - HYPERTENSIVE HEART DISEASE WITH HEART FAILURE 3,349 10.12%
4. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 3,137 9.48%
5. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W
(ACUTE) EXACERBATION 2,766 8.36%
6. N390 - URINARY TRACT INFECTION, SITE NOT SPECIFIED 2,709 8.19%
7. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 2,507 7.58%
8. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL
INFARCTION 2,235 6.76%
9. M1711 - UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT
KNEE 1,961 5.93%
10. J690 - PNEUMONITIS DUE TO INHALATION OF FOOD AND
VOMIT 1,932 5.84%
Total 33,086 100.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 28
3) BENEFICIARY DEMOGRAPHICS POSSIBLE DATA SOURCE
Demographics Number of Beneficiaries Percent of Beneficiaries
Sex/Gender
Female 695 61.56%
Male 434 38.44%
Unknown 0 0.00%
Total 1,129 100.00%
Race
Asian 6 0.53%
Black 43 3.81%
Hispanic 9 0.80%
North American Native 0 0.00%
Other 14 1.24%
Unknown 13 1.15%
White 1,044 92.47%
Total 1,129 100.00%
Age
Under 65 104 9.21%
65-70 106 9.39%
71-80 312 27.64%
81-90 399 35.34%
91+ 208 18.42%
Total 1,129 100.00%
4) PROVIDER REVIEWS SETTINGS
Setting
Number of
Providers
Percent of
Providers
0: Acute Care Unit of an Inpatient Facility 48 15.53%
1: Distinct Psychiatric Facility 3 0.97%
2: Distinct Rehabilitation Facility 6 1.94%
3: Distinct Skilled Nursing Facility 216 69.90%
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 Rural Health Clinic (RHC) 0 0.00%
9: Provider Based Rural Health Clinic (RHC) 0 0.00%
C: Free Standing Ambulatory Surgery Center 0 0.00%
G: End Stage Renal Disease Unit 1 0.32%
H: Home Health Agency 12 3.88%
N: Critical Access Hospital 1 0.32%
O: Setting does not fit into any other existing setting code 0 0.00%
Q: Long-Term Care Facility 5 1.62%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 29
Setting
Number of
Providers
Percent of
Providers
R: Hospice 14 4.53%
S: Psychiatric Unit of an Inpatient Facility 2 0.65%
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 0.32%
Z: Swing Bed Designation for Critical Access Hospitals 0 0.00%
Other 0 0.00%
Total 309 100.00%
5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF Category Codes
Number
of
Concerns
Number of
Concerns
Confirmed
Percent
Confirmed
Concerns
C01: Apparently did not obtain pertinent history and/or findings from
examination 1 0 0.00%
C02: Apparently did not make appropriate diagnoses and/or assessments 11 0 0.00%
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)]
18 0 0.00%
C04: Apparently did not carry out an established plan in a competent
and/or timely fashion 5 2 40.00%
C05: Apparently did not appropriately assess and/or act on changes in
clinical/other status results 1 0 0.00%
C06: Apparently did not appropriately assess and/or act on laboratory
tests or imaging study results 1 0 0.00%
C07: Apparently did not establish adequate clinical justification for a
procedure which carries patient risk and was performed 0 0 0.00%
C08: Apparently did not perform a procedure that was indicated (other
than lab and imaging, see C09) 2 0 0.00%
C09: Apparently did not obtain appropriate laboratory tests and/or
imaging studies 1 0 0.00%
C10: Apparently did not develop and initiate appropriate discharge,
follow-up, and/or rehabilitation plans 0 0 0.00%
C11: Apparently did not demonstrate that the patient was ready for
discharge 1 0 0.00%
C12: Apparently did not provide appropriate personnel and/or resources 0 0 0.00%
C13: Apparently did not order appropriate specialty consultation 2 0 0.00%
C14: Apparently specialty consultation process was not completed in a
timely manner 0 0 0.00%
C15: Apparently did not effectively coordinate across disciplines 0 0 0.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 30
Quality of Care (“C” Category) PRAF Category Codes
Number
of
Concerns
Number of
Concerns
Confirmed
Percent
Confirmed
Concerns
C16: Apparently did not ensure a safe environment (medication errors,
falls, pressure ulcers, transfusion reactions, nosocomial infection) 3 0 0.00%
C17: Apparently did not order/follow evidence-based practices 1 0 0.00%
C18: Apparently did not provide medical record documentation that
impacts patient care 0 0 0.00%
C40: Apparently did not follow up on patient’s non-compliance 0 0 0.00%
C99: Other quality concern not elsewhere classified 2 0 0.00%
Total 49 2 4.08%
*QII data is not included in the Contract Year 1 (CY1) BFCC-QIO 12th SOW Annual Medical Services Review
Report. QII referrals were paused during the date range in this report due to procurement process and
transition from 11th to 12th Statement of Work.
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Reviews by Notification Type
Number of
Reviews
Percent
of Total
Notice of Non-coverage FFS Preadmission/Admission Notice - (Admission and
Preadmission/HINN 1) 21 1.99%
Notice of Non-coverage Request for BFCC-QIO Concurrence - (Request for BFCC-
QIO Concurrence/HINN 10) 1 0.09%
MA Appeal Review (CORF, HHA, SNF) - (Grijalva) 288 27.35%
FFS Expedited Appeal (CORF, HHA, Hospice, SNF) - (BIPA) 560 53.18%
Notice of Non-coverage Hospital Discharge Notice - Attending Physician Concurs -
(FFS Weichardt) 157 14.91%
MA Notice of Non-coverage Hospital Discharge Notice - Attending Physician Concurs
- (MA Weichardt) 26 2.47%
Total 1,053 100.00%
Quality of Care Concerns Referred for Quality Improvement Initiatives (QIIs)
Number of Concerns Referred for QII Percent of Quality of Care Concerns
Referred for QII
N/A* N/A*
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 31
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeal Reviews by Geographic Area – Urban and Rural
Geographic Area Number of Providers
Percent of
Providers in State
Percent of Providers in
Service Area
Urban 291 98.31% 90.56%
Rural 5 1.69% 8.89%
Unknown 0 0.00% 0.55%
Total 296 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural
Geographic Area Number of Providers
Percent of
Providers in State
Percent of Providers in
Service Area
Urban 13 100.00% 92.86%
Rural 0 0.00% 7.14%
Unknown 0 0.00% 0.00%
Total 13 100.00% 100.00%
8) IMMEDIATE ADVOCACY CASES
Number of Beneficiary
Complaints
Number of Immediate
Advocacy Cases
Percent of Total Beneficiary Complaints
Resolved by Immediate Advocacy
59 43 72.88%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 32
KEPRO BFCC-QIO REGION #1 – STATE OF NEW HAMPSHIRE
1) TOTAL NUMBER OF REVIEWS
Review Type
Number of
Reviews
Percent of
Total Reviews
Quality of Care Review (Beneficiary Complaint) 6 3.14%
Quality of Care Review (All Other Selection Reasons) 0 0.00%
Notice of Non-coverage (Admission and Preadmission/HINN 1) 6 3.14%
Notice of Non-coverage (BIPA) 47 24.61%
Notice of Non-coverage (Grijalva) 58 30.37%
Notice of Non-coverage (Weichardt) 73 38.22%
Notice of Non-coverage (Request for QIO Concurrence/HINN 10) 0 0.00%
EMTALA 5 Day 1 0.52%
EMTALA 60 Day 0 0.00%
Total 191 100.00%
2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses
Number of
Beneficiaries
Percent of
Beneficiaries
1. A419 - SEPSIS, UNSPECIFIED ORGANISM 2,038 28.11%
2. I130 - HYP HRT & CHR KDNY DIS W HRT FAIL AND STG 1-
4/UNSP CHR KDNY 776 10.70%
3. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL
INFARCTION 711 9.81%
4. I110 - HYPERTENSIVE HEART DISEASE WITH HEART FAILURE 710 9.79%
5. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 599 8.26%
6. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 586 8.08%
7. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W
(ACUTE) EXACERBATION 523 7.21%
8. N390 - URINARY TRACT INFECTION, SITE NOT SPECIFIED 507 6.99%
9. M1611 - UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT HIP 422 5.82%
10. I480 - PAROXYSMAL ATRIAL FIBRILLATION 379 5.23%
Total 7,251 100.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 33
3) BENEFICIARY DEMOGRAPHICS POSSIBLE DATA SOURCE
Demographics Number of Beneficiaries Percent of Beneficiaries
Sex/Gender
Female 128 58.45%
Male 91 41.55%
Unknown 0 0.00%
Total 219 100.00%
Race
Asian 0 0.00%
Black 0 0.00%
Hispanic 1 0.46%
North American Native 0 0.00%
Other 1 0.46%
Unknown 5 2.28%
White 212 96.80%
Total 219 100.00%
Age
Under 65 38 17.35%
65-70 35 15.98%
71-80 49 22.37%
81-90 74 33.79%
91+ 23 10.50%
Total 219 100.00%
4) PROVIDER REVIEWS SETTINGS
Setting
Number of
Providers
Percent of
Providers
0: Acute Care Unit of an Inpatient Facility 13 20.31%
1: Distinct Psychiatric Facility 0 0.00%
2: Distinct Rehabilitation Facility 1 1.56%
3: Distinct Skilled Nursing Facility 39 60.94%
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 Rural Health Clinic (RHC) 0 0.00%
9: Provider Based Rural Health Clinic (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 2 3.13%
N: Critical Access Hospital 4 6.25%
O: Setting does not fit into any other existing setting code 0 0.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 34
Setting
Number of
Providers
Percent of
Providers
Q: Long-Term Care Facility 0 0.00%
R: Hospice 4 6.25%
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 1 1.56%
Other 0 0.00%
Total 64 100.00%
5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF Category Codes
Number
of
Concerns
Number of
Concerns
Confirmed
Percent
Confirmed
Concerns
C01: Apparently did not obtain pertinent history and/or findings from
examination 0 0 0.00%
C02: Apparently did not make appropriate diagnoses and/or assessments 3 0 0.00%
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)]
3 1 33.33%
C04: Apparently did not carry out an established plan in a competent
and/or timely fashion 0 0 0.00%
C05: Apparently did not appropriately assess and/or act on changes in
clinical/other status results 0 0 0.00%
C06: Apparently did not appropriately assess and/or act on laboratory
tests or imaging study results 0 0 0.00%
C07: Apparently did not establish adequate clinical justification for a
procedure which carries patient risk and was performed 0 0 0.00%
C08: Apparently did not perform a procedure that was indicated (other
than lab and imaging, see C09) 1 0 0.00%
C09: Apparently did not obtain appropriate laboratory tests and/or
imaging studies 0 0 0.00%
C10: Apparently did not develop and initiate appropriate discharge,
follow-up, and/or rehabilitation plans 2 0 0.00%
C11: Apparently did not demonstrate that the patient was ready for
discharge 0 0 0.00%
C12: Apparently did not provide appropriate personnel and/or resources 0 0 0.00%
C13: Apparently did not order appropriate specialty consultation 0 0 0.00%
C14: Apparently specialty consultation process was not completed in a
timely manner 0 0 0.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 35
Quality of Care (“C” Category) PRAF Category Codes
Number
of
Concerns
Number of
Concerns
Confirmed
Percent
Confirmed
Concerns
C15: Apparently did not effectively coordinate across disciplines 0 0 0.00%
C16: Apparently did not ensure a safe environment (medication errors,
falls, pressure ulcers, transfusion reactions, nosocomial infection) 0 0 0.00%
C17: Apparently did not order/follow evidence-based practices 0 0 0.00%
C18: Apparently did not provide medical record documentation that
impacts patient care 0 0 0.00%
C40: Apparently did not follow up on patient’s non-compliance 0 0 0.00%
C99: Other quality concern not elsewhere classified 1 0 0.00%
Total 10 1 10.00%
*QII data is not included in the Contract Year 1 (CY1) BFCC-QIO 12th SOW Annual Medical Services Review
Report. QII referrals were paused during the date range in this report due to procurement process and
transition from 11th to 12th Statement of Work.
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Reviews by Notification Type
Number of
Reviews
Percent
of Total
Notice of Non-coverage FFS Preadmission/Admission Notice - (Admission and
Preadmission/HINN 1) 6 3.53%
Notice of Non-coverage Request for BFCC-QIO Concurrence - (Request for BFCC-
QIO Concurrence/HINN 10) 0 0.00%
MA Appeal Review (CORF, HHA, SNF) - (Grijalva) 50 29.41%
FFS Expedited Appeal (CORF, HHA, Hospice, SNF) - (BIPA) 43 25.29%
Notice of Non-coverage Hospital Discharge Notice - Attending Physician Concurs -
(FFS Weichardt) 63 37.06%
MA Notice of Non-coverage Hospital Discharge Notice - Attending Physician Concurs
- (MA Weichardt) 8 4.71%
Total 170 100.00%
Quality of Care Concerns Referred for Quality Improvement Initiatives (QIIs)
Number of Concerns Referred for QII Percent of Quality of Care Concerns
Referred for QII
N/A* N/A*
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 36
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeal Reviews by Geographic Area – Urban and Rural
Geographic Area Number of Providers
Percent of
Providers in State
Percent of Providers in
Service Area
Urban 49 77.78% 90.56%
Rural 13 20.63% 8.89%
Unknown 1 1.59% 0.55%
Total 63 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural
Geographic Area Number of Providers
Percent of
Providers in State
Percent of Providers in
Service Area
Urban 3 75.00% 92.86%
Rural 1 25.00% 7.14%
Unknown 0 0.00% 0.00%
Total 4 100.00% 100.00%
8) IMMEDIATE ADVOCACY CASES
Number of Beneficiary
Complaints
Number of Immediate
Advocacy Cases
Percent of Total Beneficiary Complaints
Resolved by Immediate Advocacy
11 5 45.45%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 37
KEPRO BFCC-QIO REGION #1 – STATE OF RHODE ISLAND
1) TOTAL NUMBER OF REVIEWS
Review Type
Number of
Reviews
Percent of
Total Reviews
Quality of Care Review (Beneficiary Complaint) 4 0.87%
Quality of Care Review (All Other Selection Reasons) 1 0.22%
Notice of Non-coverage (Admission and Preadmission/HINN 1) 10 2.18%
Notice of Non-coverage (BIPA) 104 22.66%
Notice of Non-coverage (Grijalva) 228 49.67%
Notice of Non-coverage (Weichardt) 111 24.18%
Notice of Non-coverage (Request for QIO Concurrence/HINN 10) 1 0.22%
EMTALA 5 Day 0 0.00%
EMTALA 60 Day 0 0.00%
Total 459 100.00%
2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses
Number of
Beneficiaries
Percent of
Beneficiaries
1. A419 - SEPSIS, UNSPECIFIED ORGANISM 833 24.52%
2. I130 - HYP HRT & CHR KDNY DIS W HRT FAIL AND STG 1-
4/UNSP CHR KDNY 439 12.92%
3. I110 - HYPERTENSIVE HEART DISEASE WITH HEART FAILURE 377 11.10%
4. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W
(ACUTE) EXACERBATION 301 8.86%
5. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 298 8.77%
6. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL
INFARCTION 297 8.74%
7. N390 - URINARY TRACT INFECTION, SITE NOT SPECIFIED 279 8.21%
8. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 215 6.33%
9. J690 - PNEUMONITIS DUE TO INHALATION OF FOOD AND
VOMIT 186 5.48%
10. M1611 - UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT HIP 172 5.06%
Total 3,397 100.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 38
3) BENEFICIARY DEMOGRAPHICS POSSIBLE DATA SOURCE
Demographics Number of Beneficiaries Percent of Beneficiaries
Sex/Gender
Female 268 63.96%
Male 151 36.04%
Unknown 0 0.00%
Total 419 100.00%
Race
Asian 1 0.24%
Black 11 2.63%
Hispanic 5 1.19%
North American Native 0 0.00%
Other 4 0.95%
Unknown 3 0.72%
White 395 94.27%
Total 419 100.00%
Age
Under 65 41 9.79%
65-70 44 10.50%
71-80 105 25.06%
81-90 166 39.62%
91+ 63 15.04%
Total 419 100.00%
4) PROVIDER REVIEWS SETTINGS
Setting
Number of
Providers
Percent of
Providers
0: Acute Care Unit of an Inpatient Facility 9 11.11%
1: Distinct Psychiatric Facility 1 1.23%
2: Distinct Rehabilitation Facility 0 0.00%
3: Distinct Skilled Nursing Facility 64 79.01%
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 Rural Health Clinic (RHC) 0 0.00%
9: Provider Based Rural Health Clinic (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 5 6.17%
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%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 39
Setting
Number of
Providers
Percent of
Providers
R: Hospice 2 2.47%
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 81 100.00%
5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF Category Codes
Number
of
Concerns
Number of
Concerns
Confirmed
Percent
Confirmed
Concerns
C01: Apparently did not obtain pertinent history and/or findings from
examination 0 0 0.00%
C02: Apparently did not make appropriate diagnoses and/or assessments 0 0 0.00%
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)]
3 0 0.00%
C04: Apparently did not carry out an established plan in a competent
and/or timely fashion 0 0 0.00%
C05: Apparently did not appropriately assess and/or act on changes in
clinical/other status results 0 0 0.00%
C06: Apparently did not appropriately assess and/or act on laboratory
tests or imaging study results 0 0 0.00%
C07: Apparently did not establish adequate clinical justification for a
procedure which carries patient risk and was performed 0 0 0.00%
C08: Apparently did not perform a procedure that was indicated (other
than lab and imaging, see C09) 1 0 0.00%
C09: Apparently did not obtain appropriate laboratory tests and/or
imaging studies 0 0 0.00%
C10: Apparently did not develop and initiate appropriate discharge,
follow-up, and/or rehabilitation plans 0 0 0.00%
C11: Apparently did not demonstrate that the patient was ready for
discharge 3 0 0.00%
C12: Apparently did not provide appropriate personnel and/or resources 0 0 0.00%
C13: Apparently did not order appropriate specialty consultation 0 0 0.00%
C14: Apparently specialty consultation process was not completed in a
timely manner 0 0 0.00%
C15: Apparently did not effectively coordinate across disciplines 0 0 0.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 40
Quality of Care (“C” Category) PRAF Category Codes
Number
of
Concerns
Number of
Concerns
Confirmed
Percent
Confirmed
Concerns
C16: Apparently did not ensure a safe environment (medication errors,
falls, pressure ulcers, transfusion reactions, nosocomial infection) 0 0 0.00%
C17: Apparently did not order/follow evidence-based practices 0 0 0.00%
C18: Apparently did not provide medical record documentation that
impacts patient care 0 0 0.00%
C40: Apparently did not follow up on patient’s non-compliance 0 0 0.00%
C99: Other quality concern not elsewhere classified 1 0 0.00%
Total 8 0 0.00%
*QII data is not included in the Contract Year 1 (CY1) BFCC-QIO 12th SOW Annual Medical Services Review
Report. QII referrals were paused during the date range in this report due to procurement process and
transition from 11th to 12th Statement of Work.
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Reviews by Notification Type
Number of
Reviews
Percent
of Total
Notice of Non-coverage FFS Preadmission/Admission Notice - (Admission and
Preadmission/HINN 1) 8 2.01%
Notice of Non-coverage Request for BFCC-QIO Concurrence - (Request for BFCC-
QIO Concurrence/HINN 10) 1 0.25%
MA Appeal Review (CORF, HHA, SNF) - (Grijalva) 188 47.12%
FFS Expedited Appeal (CORF, HHA, Hospice, SNF) - (BIPA) 96 24.06%
Notice of Non-coverage Hospital Discharge Notice - Attending Physician Concurs -
(FFS Weichardt) 67 16.79%
MA Notice of Non-coverage Hospital Discharge Notice - Attending Physician Concurs
- (MA Weichardt) 39 9.77%
Total 399 100.00%
Quality of Care Concerns Referred for Quality Improvement Initiatives (QIIs)
Number of Concerns Referred for QII Percent of Quality of Care Concerns
Referred for QII
N/A* N/A*
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 41
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeal Reviews by Geographic Area – Urban and Rural
Geographic Area Number of Providers
Percent of
Providers in State
Percent of Providers in
Service Area
Urban 81 100.00% 90.56%
Rural 0 0.00% 8.89%
Unknown 0 0.00% 0.55%
Total 81 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural
Geographic Area Number of Providers
Percent of
Providers in State
Percent of Providers in
Service Area
Urban 1 100.00% 92.86%
Rural 0 0.00% 7.14%
Unknown 0 0.00% 0.00%
Total 1 100.00% 100.00%
8) IMMEDIATE ADVOCACY CASES
Number of Beneficiary
Complaints
Number of Immediate
Advocacy Cases
Percent of Total Beneficiary Complaints
Resolved by Immediate Advocacy
10 8 80.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 42
KEPRO BFCC-QIO REGION #1 – STATE OF VERMONT
1) TOTAL NUMBER OF REVIEWS
Review Type
Number of
Reviews
Percent of
Total Reviews
Quality of Care Review (Beneficiary Complaint) 0 0.00%
Quality of Care Review (All Other Selection Reasons) 0 0.00%
Notice of Non-coverage (Admission and Preadmission/HINN 1) 0 0.00%
Notice of Non-coverage (BIPA) 31 36.05%
Notice of Non-coverage (Grijalva) 30 34.88%
Notice of Non-coverage (Weichardt) 25 29.07%
Notice of Non-coverage (Request for QIO Concurrence/HINN 10) 0 0.00%
EMTALA 5 Day 0 0.00%
EMTALA 60 Day 0 0.00%
Total 86 100.00%
2) TOP 10 PRINCIPAL MEDICAL DIAGNOSES
Top 10 Medical Diagnoses
Number of
Beneficiaries
Percent of
Beneficiaries
1. A419 - SEPSIS, UNSPECIFIED ORGANISM 688 21.06%
2. J189 - PNEUMONIA, UNSPECIFIED ORGANISM 361 11.05%
3. I110 - HYPERTENSIVE HEART DISEASE WITH HEART FAILURE 331 10.13%
4. I214 - NON-ST ELEVATION (NSTEMI) MYOCARDIAL
INFARCTION 329 10.07%
5. J441 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W
(ACUTE) EXACERBATION 306 9.37%
6. I130 - HYP HRT & CHR KDNY DIS W HRT FAIL AND STG 1-
4/UNSP CHR KDNY 304 9.31%
7. N390 - URINARY TRACT INFECTION, SITE NOT SPECIFIED 292 8.94%
8. N179 - ACUTE KIDNEY FAILURE, UNSPECIFIED 270 8.26%
9. M1712 - UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT KNEE 199 6.09%
10. M1711 - UNILATERAL PRIMARY OSTEOARTHRITIS, RIGHT
KNEE 187 5.72%
Total 3,267 100.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 43
3) BENEFICIARY DEMOGRAPHICS POSSIBLE DATA SOURCE
Demographics Number of Beneficiaries Percent of Beneficiaries
Sex/Gender
Female 40 57.14%
Male 30 42.86%
Unknown 0 0.00%
Total 70 100.00%
Race
Asian 0 0.00%
Black 1 1.43%
Hispanic 0 0.00%
North American Native 0 0.00%
Other 1 1.43%
Unknown 0 0.00%
White 68 97.14%
Total 70 100.00%
Age
Under 65 7 10.00%
65-70 6 8.57%
71-80 16 22.86%
81-90 29 41.43%
91+ 12 17.14%
Total 70 100.00%
4) PROVIDER REVIEWS SETTINGS
Setting
Number of
Providers
Percent of
Providers
0: Acute Care Unit of an Inpatient Facility 5 21.74%
1: Distinct Psychiatric Facility 1 4.35%
2: Distinct Rehabilitation Facility 0 0.00%
3: Distinct Skilled Nursing Facility 13 56.52%
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 Rural Health Clinic (RHC) 0 0.00%
9: Provider Based Rural Health Clinic (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 1 4.35%
N: Critical Access Hospital 1 4.35%
O: Setting does not fit into any other existing setting code 0 0.00%
Q: Long-Term Care Facility 0 0.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 44
Setting
Number of
Providers
Percent of
Providers
R: Hospice 1 4.35%
S: Psychiatric Unit of an Inpatient Facility 0 0.00%
T: Rehabilitation Unit of an Inpatient Facility 1 4.35%
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 23 100.00%
5) QUALITY OF CARE CONCERNS CONFIRMED
Quality of Care (“C” Category) PRAF Category Codes
Number
of
Concerns
Number of
Concerns
Confirmed
Percent
Confirmed
Concerns
C01: Apparently did not obtain pertinent history and/or findings from
examination 0 0 0.00%
C02: Apparently did not make appropriate diagnoses and/or assessments 0 0 0.00%
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)]
0 0 0.00%
C04: Apparently did not carry out an established plan in a competent
and/or timely fashion 0 0 0.00%
C05: Apparently did not appropriately assess and/or act on changes in
clinical/other status results 0 0 0.00%
C06: Apparently did not appropriately assess and/or act on laboratory
tests or imaging study results 0 0 0.00%
C07: Apparently did not establish adequate clinical justification for a
procedure which carries patient risk and was performed 0 0 0.00%
C08: Apparently did not perform a procedure that was indicated (other
than lab and imaging, see C09) 0 0 0.00%
C09: Apparently did not obtain appropriate laboratory tests and/or
imaging studies 0 0 0.00%
C10: Apparently did not develop and initiate appropriate discharge,
follow-up, and/or rehabilitation plans 0 0 0.00%
C11: Apparently did not demonstrate that the patient was ready for
discharge 0 0 0.00%
C12: Apparently did not provide appropriate personnel and/or resources 0 0 0.00%
C13: Apparently did not order appropriate specialty consultation 0 0 0.00%
C14: Apparently specialty consultation process was not completed in a
timely manner 0 0 0.00%
C15: Apparently did not effectively coordinate across disciplines 0 0 0.00%
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 45
Quality of Care (“C” Category) PRAF Category Codes
Number
of
Concerns
Number of
Concerns
Confirmed
Percent
Confirmed
Concerns
C16: Apparently did not ensure a safe environment (medication errors,
falls, pressure ulcers, transfusion reactions, nosocomial infection) 0 0 0.00%
C17: Apparently did not order/follow evidence-based practices 0 0 0.00%
C18: Apparently did not provide medical record documentation that
impacts patient care 0 0 0.00%
C40: Apparently did not follow up on patient’s non-compliance 0 0 0.00%
C99: Other quality concern not elsewhere classified 0 0 0.00%
Total 0 0 0.00%
*QII data is not included in the Contract Year 1 (CY1) BFCC-QIO 12th SOW Annual Medical Services Review
Report. QII referrals were paused during the date range in this report due to procurement process and
transition from 11th to 12th Statement of Work.
6) BENEFICIARY APPEALS OF PROVIDER DISCHARGE/SERVICE TERMINATIONS AND DENIALS OF
HOSPITAL ADMISSIONS OUTCOMES BY NOTIFICATION TYPE
Appeal Reviews by Notification Type
Number of
Reviews
Percent
of Total
Notice of Non-coverage FFS Preadmission/Admission Notice - (Admission and
Preadmission/HINN 1) 0 0.00%
Notice of Non-coverage Request for BFCC-QIO Concurrence - (Request for BFCC-
QIO Concurrence/HINN 10) 0 0.00%
MA Appeal Review (CORF, HHA, SNF) - (Grijalva) 23 30.67%
FFS Expedited Appeal (CORF, HHA, Hospice, SNF) - (BIPA) 28 37.33%
Notice of Non-coverage Hospital Discharge Notice - Attending Physician Concurs -
(FFS Weichardt) 22 29.33%
MA Notice of Non-coverage Hospital Discharge Notice - Attending Physician Concurs
- (MA Weichardt) 2 2.67%
Total 75 100.00%
Quality of Care Concerns Referred for Quality Improvement Initiatives (QIIs)
Number of Concerns Referred for QII Percent of Quality of Care Concerns
Referred for QII
N/A* N/A*
BFCC-QIO 12th SOW Annual Medical Services Review Report
KEPRO, Region 1, June 8 – December 31, 2019
Page | 46
7) REVIEWS BY GEOGRAPHIC AREA – URBAN AND RURAL
Table 7A: Appeal Reviews by Geographic Area – Urban and Rural
Geographic Area Number of Providers
Percent of
Providers in State
Percent of Providers in
Service Area
Urban 8 36.36% 90.56%
Rural 14 63.64% 8.89%
Unknown 0 0.00% 0.55%
Total 22 100.00% 100.00%
Table 7B: Quality of Care Reviews by Geographic Area – Urban and Rural
Geographic Area Number of Providers
Percent of
Providers in State
Percent of Providers in
Service Area
Urban 0 0.00% 0.00%
Rural 0 0.00% 0.00%
Unknown 0 0.00% 0.00%
Total 0 0.00% 0.00%
8) IMMEDIATE ADVOCACY CASES
Number of Beneficiary
Complaints
Number of Immediate
Advocacy Cases
Percent of Total Beneficiary Complaints
Resolved by Immediate Advocacy
3 3 100.00%
Publication No. R1-92-5/2020. This material was prepared by KEPRO, a Medicare Quality Improvement Organization 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.