Ghostbusters and QIO Program Turn 30: Who You Gonna Call for Medicare Concerns?

 

Primaris will no longer handle Missouri Medicare case reviews beginning August 1

Thirty years ago, Ghostbusters made the question “Who you gonna call” go viral long before the days of social media. 1984 was the same year Quality Improvement Organizations (QIOs), like Missouri-based Primaris, began answering the call of Medicare patients with concerns about their care or when they believe a healthcare service is ending too soon.

Beginning August 1, 2014, Missourian patients and providers will no longer call health care quality-improvement consulting company Primaris for Medicare quality review case work and appeals. All current and future beneficiary quality review case work and appeals will be conducted by KEPRO, located in Seven Hills, Ohio.

What does this mean for you and your organization?

provider email infographicAs of August 1, 2014, KEPRO will be the new Beneficiary and Family Centered Care (BFCC) QIO in the state and will work to protect the quality and safety of care delivered to Medicare beneficiaries.

To avoid processing delays and errors, please continue submitting cases and requests to Primaris through Thursday, July 31, 2014 using your current process.

Beginning Friday, August 1, 2014, healthcare providers and Medicare beneficiaries must contact KEPRO toll-free at 1.855.408.8557 for all appeal requests and Quality of Care concerns. All outstanding Higher-Weighted DRG medical record requests after the above date should be mailed to:

KEPRO
5201 W. Kennedy Blvd, Suite 900
Tampa, FL 33609

There are several steps your organization must take during this transition, including:

  • Updating all copies of the Notice of Medicare Non-Coverage, which informs beneficiaries that Medicare may stop paying for their care.
  • Replacing all print and electronic copies of beneficiary resources that include Primaris contact information.
  • Updating policies and procedures that contain a reference to contact Primaris.

 Transition plan updates

Primaris is working with KEPRO and CMS to ensure a seamless transition with no disruption in case review services.

The Centers for Medicare and Medicaid Services (CMS) awarded the contract to KEPRO as part of the first phase of restructuring the QIO program, separating the program’s case review and monitoring activities from the quality improvement activities of QIOs.

The first phase of restructuring also moves from having 53 case review contracts to having just two in the entire country. KEPRO will provide case review services for Missouri, 32 other states and the District of Columbia.

Medicare made changes to the program to ensure patient needs are better met by designating a special Beneficiary and Family Centered Care (BFCC) QIO just to address patient and family concerns.

Quality Innovation Network QIOs

There will be a second QIO that will work with hospitals and doctors to help them with their quality improvement activities. In July 2014, CMS will award QIN-QIO contracts to organizations that will work directly with providers and communities on data-driven quality initiatives.

Primaris has submitted a proposal to be a part of one of these new regional QIN-QIOs and will continue to provide updates to the provider community as more information becomes available.

More information on the QIO program can be found at www.QIOprogram.org or by contacting 1-800-MEDICARE. For more information about Primaris, please visit www.primaris.org.