Review Services and Appeals
The Kansas Foundation for Medical Care, Inc. (KFMC) serves as the Quality Improvement and Peer Review Organization for the state of Kansas. KFMC has peer review contracts of medical cases with organizations such as the Centers for Medicare & Medicaid Services (CMS), Kansas Health Policy Authority (KHPA), and Kansas Department of Labor Worker's Compensation. KFMC serves as the external review organization for the Kansas Insurance Department (KID). Case review is made up of dedicated staff of healthcare professionals including nurses and coders. Physician consultants are available to carry out a complete and unbiased peer review of healthcare records, answering questions of appropriateness of care, quality of care, medical necessity, and coding.
Medicare & Medicaid Contracts
Review work consists of reviewing beneficiary complaints, discharge reviews, higher weighted DRGs, FI referrals, and/or other selections for quality/utilization/coding issues.
Case review staff also provides assistance in the area of quality improvement activities.
Following KFMC's review process, a physician reviewer evaluates the medical record to determine if the quality of care received met professionally recognized standards. When quality of care issues are identified, the physician reviewer establishes the source of the issue, the severity of the issue, and whether an improvement plan is needed. The issues are communicated to the source, such as the attending physician or provider, and an opportunity is given for exchange of information before a final decision is made. The final decision is communicated to the source, the provider (if different) and the Medicare beneficiary (if it stemmed from a beneficiary complaint).
The case review team evaluates patterns of statewide practice variation, provides feedback and suggestions for improving practice patterns to the healthcare community, and monitors to ensure resolution of issues on an ongoing basis. KFMC may refer the responsible party for the issue to CMS or the Office of the Inspector General when issues are egregious or not resolved after time.
Private Review Contracts
Reviews quality/utilization/coding issues according the contract requirement and/or requests.