Livanta BFCC-QIO - Case Types
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Case Types

Appeals

Medicare beneficiaries, their family members or advocates may file an appeal of a hospital discharge if he or she does not feel well enough to leave. Beneficiaries may also appeal a discharge from a skilled nursing facility, critical access hospital, home health agency, hospice, or rehabilitation center if he or she does not agree with a decision to stop providing skilled care and services. The hospital or facility will provide the patient with “An Important Message from Medicare” which explains how to file an appeal with Livanta. Beneficiaries who choose to appeal a discharge decision must receive the Detailed Notice of Discharge (DND) from the hospital or facility. Upon receipt of an appeal, Livanta will immediately request the medical records from the hospital or facility to determine whether a continued stay is appropriate and medically necessary. While a hospital appeal is in process, the beneficiary may stay in the hospital, and is not required to pay for the extra days in the hospital.

Appeals are usually handled within 24 to 48 hours.

Medicare beneficiaries enrolled in a Medicare Advantage Plan (also known as a managed care plan, HMO, Preferred Provider Organization or Accountable Care Organization) may also file an appeal. The beneficiary must be provided with a letter including the planned discharge and an explanation of how to file an appeal.

Quality of Care Complaints

Beneficiaries or their appointed representatives have the right to file a quality of care complaint about health care services provided. There are two ways that beneficiaries can file a complaint. A beneficiary can call Livanta at 1-877-588-1123, or complete and mail the Medicare Quality of Care Complaint Form, which is found on the Livanta website.

Upon receipt of the written complaint and authorization, a Livanta staff member will contact the beneficiary by phone. Livanta will ask questions to further clarify details about the complaint and ask for the provider’s name, address, phone number and the dates of service. Livanta will request the patient’s medical record. A physician of matching speciality will review the medical record to determine whether the care provided met the medical standard of care, or whether the standard of care were not met. The review process could take a few months to complete. When the review is complete, Livanta will notify the provider and the patient by phone and in writing. If the review of a case results in a confirmed quality of care concern, the case is referred to the CMS designated Quality Innovation Network Quality Improvement Organization (QIN-QIO) for the potential initiation of a quality improvement plan. Quality improvement plans are designed to engage health care providers in making system or care delivery changes to prevent a similar problem from occurring in the future.

Higher-Weighted Diagnostic Related Group (DRG) Reviews

Inpatient hospital payment adjustments that have been processed by the Medicare Administrative Contractors (MACs) and result in higher-weighted DRG assignments are reviewed by Livanta to ensure that the diagnosis and procedure codes reported are supported by the documentation in the medical record. These cases also undergo review to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting.

Hospitals are provided with an opportunity for discussion about any disagreements before Livanta’s case decisions are sent to the MAC for payment adjustments. Hospitals may then request that Livanta perform a one-time re-review of these case decisions by a reviewer not involved in the original determination.

Referral Reviews

QIOs are required to conduct quality reviews when complaints about Medicare beneficiaries' health care are received from sources other than the beneficiary. These referrals come from a variety of state and federal agencies and organizations that include, but are not limited to: - the Centers for Medicare & Medicaid Services (CMS) - the Office of the Inspector General (OIG) - the Federal Bureau of Investigation (FBI) - the Centers for Health Dispute Resolution (CHDR) - the Joint Commission - Medicare Administrative Contractors (MACs)

Immediate Advocacy

Immediate Advocacy is an informal process used by the BFCC-QIO to quickly resolve a concern or complaint. The informal process starts when a beneficiary, family member, or advocate gives Livanta a verbal approval to address the concern or complaint. Upon receiving the verbal approval, Livanta will contact the provider of services, and will triage the resolution of the issue.

Livanta will contact the provider to inform them of the beneficiary request for assistance. The provider must agree to participate in the resolution of the issue. If the provider declines to participate in the Immediate Advocacy process, the beneficiary will be informed by Livanta that the patient may file a written complaint. Immediate Advocacy is appropriate when items or services of concern are incidental to the medical care provided, but are not related to the quality of care.

Examples of Immediate Advocacy include such things as the prescribed durable medical equipment has not been delivered to the beneficiary, or the home health agency representative does not show up for a scheduled appointment. Issues addressed through the Immediate Advocacy process are usually resolved within 8 hours, but no longer than 2 business days. Immediate Advocacy is not applicable to beneficiaries who wish to remain anonymous, and the intervention can be terminated at any time if the beneficiary indicates that he or she no longer needs Livanta’s assistance. Livanta’s staff will advise the beneficiary if the formal complaint process is more appropriate.

EMTALA

All EMTALA reviews conducted by Livanta are at the sole directive of the Centers for Medicare & Medicaid Services (CMS) Regional Offices. The Emergency Medical Treatment & Labor Act (EMTALA) ensures public access to emergency services regardless of the beneficiary’sc ability to pay. Medicare-participating hospitals that offer emergency services must provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC). Hospitals are then required to provide medical care and treatment for patients with EMCs.

Providers found to be in violation of the EMTALA provisions may be subject to civil monetary penalties or Medicare exclusion sanctions at the direction of the Office of the Inspector General (OIG).