Wednesday, August 13, 2014

The New QIO Program and Beneficiary Complaints

Marguerite McLaughlin

As you may have heard, there have been changes within the QIO community involving Beneficiary Protection. AHCA recently identified the two organizations that will hold the Beneficiary Protection contract for each region-Livanta and KePro. Under the former system, each QIO had a division that investigated beneficiary complaints. With the new scope of work (SoW) the beneficiary protection work was taken out of the local QIO and given to Livanta and KePro to administer for the entire nation. This began on August 1 when the new contract was executed.

This important function ensures the safety of beneficiaries, provides an appeal process regarding one's care, and is a key element in our national dialogue around transitions of care. If you are not aware of how this system works here is an example: if my 89 year old Mom is in the hospital and the hospital wants to discharge her and my family feels and has reason to believe that she is in no condition to move or transfer, we can appeal that decision. Mom gets to stay at the hospital until the matter is investigated and a decision is reached. This formerly local process is now being administered nationally by the two companies.

AHCA is aware from many of our State Affiliates, as well as providers, that there have been a wide array of problems affecting Medicare beneficiaries in the short time that the new contract has been in place. AHCA is working with partners and makes the following recommendations:

1. The Beneficiaries should call 1-800-Medicare and they should not accept being told to call Livanta or KePro. We would recommend they (or their advocate) ask for a supervisor to let them know they are having problems exercising their Medicare beneficiary appeal rights! (This specific language is important)
2. Make any issues known to your local State Survey Agency and Ombudsman. This will help to bring the problem to light on many fronts to ensure it is resolved soon.
3. The local QIO, who many people counted on, no longer is doing the Beneficiary Protection work so they are unable to assist.

AHCA, in the meantime, is working hard to obtain more information and is working with partners to resolve this issue. Safety and quality care are a critical concern to us.

No comments:

Post a Comment