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Knowledge Expansion

Getting to know KEPRO: What providers should know about quality improvement organizations

Insight Article

Quality & Patient Experience

Coding & Documentation

Michelle Ann Richards BSHA, CPC, CPCO, CPMA, SHRM-SCP
If you’re unfamiliar with Keystone Peer Review Organization Inc. (KEPRO), you might start by assessing its list of clients: 
  • Centers for Medicare & Medicaid Services (CMS)
  • U.S. Department of Defense
  • 10 Medicaid agencies
  • County governments
  • Health plans
  • Third-party administrators
 
More specifically, KEPRO is a Quality Improvement Organization (QIO) serving Medicare beneficiaries for more than a quarter century.

The QIO program is the cornerstone of Medicare’s efforts to improve the quality of care and health outcomes for Medicare beneficiaries. KEPRO is the Beneficiary and Family Centered Care QIO (BFCC-QIO) for more than 30 states. KEPRO offers information and assistance to providers, patients and families regarding beneficiary complaints, discharge appeals and immediate advocacy in states. 

Do not feel bad if you have never heard of KEPRO. I conducted a quick poll prior to writing this article and found that 4 out of 10 coders and billers surveyed had no idea KEPRO existed.

KEPRO key facts

Headquartered in Pennsylvania, KEPRO also has offices in Alabama, Florida, Illinois, Maine, Maryland, Massachusetts, Minnesota, Ohio, Oregon, South Carolina, Tennessee, Virginia and West Virginia. KEPRO is URAC accredited in case management and health utilization management. It is also National Institute of Standards and Technology (NIST) and Federal Information Security Management Act (FISMA) certified.

From 2012 to 2019, states under KEPRO were categorized by area:
  • Area 2: Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia
  • Area 3: Alabama, Arkansas, Colorado, Kentucky, Louisiana, Mississippi, Montana, New Mexico, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, Utah, Wyoming
  • Area 4: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio, Wisconsin

History of QIOs

In 1982, Congress established Utilization and Quality Control Peer Review Organizations (now known as QIOs) to perform two broad functions:
  1. Promote quality healthcare services for Medicare beneficiaries
  2. Determine whether services rendered are medically necessary, appropriate and meet professionally recognized standards of care.
 
CMS also contracted with QIOs to validate provider-coding assignments, which many times affected reimbursement.

Although founded in 1985, KEPRO did not start focusing on the healthcare payer market until 2012. KEPRO’s first four-year contract timeline offers a sense of how quickly the organization evolved:

July 1, 2013: Minnesota Health Care Programs Contract

KEPRO began work as the Medical Review Agent verifying program eligibility and determining medical necessity of healthcare services in Minnesota.1

Aug. 14, 2013: New Hampshire Medicaid Contract

KEPRO provided prior authorization based on evidence-based clinical assessment for the state’s Medicaid fee-for-service program beneficiaries.2

July 14, 2014: New federal law for Medicare provider enrollment

Medicare providers in CMS Areas 2, 3 and 4 received notification of new federal law enrollment mandates. To participate in the Medicare program, federal law would now require certain providers to have a Memorandum of Agreement (MOA) with a QIO.3

The MOA included “permissible disclosures” for health oversight activities in accordance with the HIPAA Privacy Rule. It further explained to providers that the Privacy Rule permitted a covered entity to disclose protected health information to a health oversight agency for oversight activities authorized by law, 45 CFR § 164.512(d)(1). Additionally, all providers were notified that KEPRO’s oversight activities were authorized by law. (See 42 USC § 1320c-5(a)(3); 42 CFR §§480.111, 480.112, 480.113) Accordingly, HIPAA permitted the disclosure of protected health information (PHI) to the QIO.

Aug. 1, 2014: KEPRO awarded CMS BFCC contracts

CMS began restructuring the QIO program to improve patient care and health outcomes and save taxpayer resources. This first phase of the restructuring awarded five areas of BFCC-QIO contractors to support the program’s case review and monitoring activities separate from the traditional quality improvement activities of the QIOs. Ohio KEPRO was awarded three CMS BFCC contracts that encompass 34 states across the nation.

July 11, 2016: KEPRO awarded TRICARE quality monitoring contract, expanded services

KEPRO was selected as the Defense Health Agency’s (DHA) TRICARE Quality Monitoring Contractor (TQMC) by the U.S. Department of Defense.4 As the TQMC, KEPRO provides independent, impartial healthcare evaluations for Military Health System beneficiaries. Simultaneously, KEPRO was awarded Oregon, Virginia and West Virginia’s Medicaid and Medicare management programs.5

KEPRO grew so fast due to all Medicare providers signing the MOA with a QIO in 2014. Federal insurers can collect data continuously from office visits, procedures and therapies. This data is used to show which Medicare providers are outside the bell curve. Once the providers are identified, electronic chart audits are completed, many times without the provider ever knowing. These chart audits can last years.

One provider was audited for five years and had not realized it was happening: He had an onsite QIO chart audit and never received the results. He assumed “no news was good news” and never asked for follow-up. 

The result of these chart audits is what helped the organization evolve so quickly. The medical reviewers found numerous physician errors. The more the QIO medical reviewers found, the more chart audits were requested, thus saving CMS millions to billions of dollars. 

Because of the huge cost savings to federal healthcare programs, more QIOs have been added. The United States is now categorized into 10 QIO regions, with two types of QIOs that work under the direction of CMS:
  1. BFCC-QIOs: BFCC-QIOs help Medicare beneficiaries exercise their right to high-quality healthcare. They manage all beneficiary complaints and quality of care reviews to ensure consistency in the review process while taking into consideration local factors important to beneficiaries and their families. They also handle cases in which beneficiaries want to appeal a healthcare provider’s decision to discharge them from the hospital or discontinue other types of services. Two designated BFCC-QIOs serve all 50 states and three territories, which are grouped into 10 regions.
  2. Quality Innovation Network (QIN)-QIOs: The QIO Program’s 14 QIN-QIOs bring Medicare beneficiaries, providers and communities together in data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care and improve clinical quality. By serving regions of two to six states each, QIN-QIOs can ensure that best practices for better care spread more quickly, while still accommodating local conditions and cultural factors.6
 
The extent of QIOs in today’s healthcare industry make them something medical group administrators and physicians should know about. The focus on quality outcomes and the potential for extensive chart audits means that your team members performing coding and billing should heed this piece of advice: “Document as though you are being watched, because you are.”

Notes:

  1. KEPRO. “KEPRO performs utilization management for the Minnesota Medicaid program.” Aug. 9, 2013. Available from: bit.ly/2w9GlHK.
  2. KEPRO. “KEPRO provides utilization management services to New Hampshire Medicaid beneficiaries.” Aug. 14, 2013. Available from: bit.ly/2HemMAb.
  3. KEPRO. “BFCC QIO Medicare MOA instructions.” July 17, 2014. Available from: bit.ly/2ONamn5.
  4. KEPRO. “KEPRO awarded TRICARE quality monitoring contract, expanded services.” July 11, 2016. Available from: bit.ly/2OIMnFt.
  5. KEPRO. “KEPRO awarded Oregon’s Medicaid and Medicaid management programs.” July 11, 2016. Available from: bit.ly/37gonAg.
  6. CMS. “Quality Improvement Organizations.” Available from: go.cms.gov/38uFBvf.

About the Author

Michelle Ann Richards
Michelle Ann Richards BSHA, CPC, CPCO, CPMA, SHRM-SCP
Owner Coding & Compliance Experts

Michelle Ann Richards can be reached at michelle@coding-compliance-experts.com. 

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