Annual Medical Services Review Report - Kansas

Kansas Foundation for Medical Care, Inc.

Time Frame: From August 1, 2004 - July 26, 2005

If you would like to receive this annual report via email as a Portable Document Format (PDF) attachment, please send email to Relations@kfmc.org. If you would prefer to receive a printed brochure by mail, please email your name and address to Relations@kfmc.org.

A. Beneficiary Complaints

Under Medicare law, Quality Improvement Organizations (QIOs) review complaints about the quality of care that Medicare patients receive. The complaints come from Medicare patients and/or their representatives. In reviewing a complaint, the QIO looks at the services a patient received and decides whether those services met standards of health care that are commonly accepted by physicians and others in the medical community.

Quality of care complaints may involve more than one concern, due to the following: (1) more than one quality of care concern in a single setting; (2) the same quality of care complaint for a single patient episode of illness involving multiple settings and/or providers; or (3) more than one quality of care concern involving more than one setting and/or provider. For example, a Medicare beneficiary complaint related to a hospital stay might include several different quality of care concerns or a beneficiary who was hospitalized and then moved into a skilled nursing facility or other outpatient hospital setting might have the same quality of care concern occur in each type of setting. Consequently, for aspecific Setting or Provider type, the number of quality of care concerns confirmed by the QIO may exceed the number of beneficiary cases reviewed.

Beneficiary Complaint Cases: Number and Review Results

Number and Rate	Review Results
Total cases reviewed by the QIO:       26	Cases with confirmed quality concern: 6
	Cases without confirmed quality concern: 20
	Cases in process (without completion date): 27

Complaint Cases by Setting or Provider

Care Setting or Care Provider	Total Number of Concerns	Number and Percent of Confirmed Concerns for the State
		Number	Percent
Hospital	69	12	17.39%
Skilled Nursing Facility (SNF) (includes SNF, swing, and swing critical access)	13	2	15.38%
Home Health Agency	0	0	0.00%
Medicare + Choice	0	0	0.00%
Physician	8	0	0.00%
Other Provider	27	5	18.52%

B. Hospital Admission and Continued Stay Concerns

Under Medicare law, QIOs review the need for inpatient hospital care. They help determine whether a patient received care in the proper place or “care setting.” This review may take place at two different times, either during or after a hospitalization. In the first instance, patients or their representatives ask the QIO to review a “Hospital Issued Notice of Non-Coverage,” or HINN, in which the hospital informs a patient that either an admission or a continued stay in a hospital is not needed. In such cases, the QIO conducts an “immediate review,” whereby the QIO reviews the case (within 2 working days following the beneficiary’s request for a pre-admission or admission HINN and within 30 days after discharge or when the beneficiary was not admitted to the hospital) and issues either a denial notice or a notice explaining that the care would be, or is, covered. In other cases where a hospital issues a HINN, but the patient does not immediately ask for a review, the QIO reviews selected cases after the fact in what is called “retrospective review.” In all reviews, the QIO staff looks carefully at the patient’s medical record to decide if an admission or continued stay is/was needed.

Reviews of Hospital Issued Notice of Non-coverage (HINN) and Notice of Discharge and Medicare Appeal Rights (NODMAR)

Type/Timing of Review	Number of Cases	Review Results
		Appropriate Cases (Agree with Notice)	Inappropriate Cases (Disagree with Notice)
HINN FFS Preadmission Notice Concurrent Immediate Review	0	0	0
HINN FFS Preadmission Notice Non-immediate Review	0	0	0
HINN FFS Admission Notice Concurrent Immediate Review	0	0	0
HINN FFS Admission Notice Non-immediate Review	0	0	0
HINN Continued Stay Notice Immediate Review—Attending Physician Concurs	2	1	1
HINN Continued Stay Notice Concurrent Non-immediate Review	0	0	0
HINN Continued Stay Notice—Attending Physician Does not Concur	2	1	1
HINN Continued Stay Retrospective	1	1	0
HINN Retrospective Monitoring Review	25	14	11
NODMAR Immediate Review (M+C)	1	0	1