Case Review Connections

Medical Director's Corner

Written by Jessica Whitley, MD, MBA

The 2025 Acentra Health Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) Annual Medical Review Services Report provides a comprehensive overview of the organization’s work supporting Medicare beneficiaries across 29 states. This report highlights Acentra Health’s role in protecting patient rights, reviewing healthcare quality, resolving beneficiary concerns, and ensuring compliance with Medicare standards.

During calendar year 2025, Acentra Health completed more than 321,000 reviews, with the majority related to Medicare Advantage post-acute appeals and hospital discharge appeals. Our organization also handled thousands of Immediate Advocacy cases. These are designed to quickly resolve beneficiary concerns related to communication, continuity of care, discharge planning, prescriptions, and access to services.

The most common diagnoses among the reviewed cases were found to be:

• Sepsis
• Heart failure
• Acute kidney failure
• Pneumonia
• Urinary tract infections
• Cardiovascular conditions

It is important to note that skilled nursing facilities represented the largest provider setting involved in reviews, accounting for nearly 80 percent of all cases. Acentra Health confirmed more than 1,200 quality-of-care concerns, many involving incomplete assessments, delayed treatment, or failures to respond to clinical changes appropriately.

Confirmed concerns that suggested systemic issues were referred to Quality Innovation Network Quality Improvement Organizations (QIN-QIO) for further quality improvement activities. Other cases were addressed directly with providers through education and technical assistance.

A major focus of the report is Acentra Health’s beneficiary support and outreach efforts. We partnered with X4 Health to pilot outreach initiatives in Louisiana, New Mexico, and Oregon, targeting underserved Medicare populations and increasing awareness of BFCC-QIO services. The initiative engaged hundreds of community organizations and demonstrated the importance of trusted local partnerships and simplified educational materials in helping beneficiaries understand their healthcare rights.

Also spotlighted are multiple beneficiary success stories that illustrate how Immediate Advocacy interventions helped resolve medication access issues, discharge safety concerns, and care coordination problems that directly affected patient well-being.

Overall, the report emphasizes Acentra Health’s commitment to improving healthcare quality. Through our commitment, we are supporting beneficiaries and families, and ensuring fair, timely medical review processes. Appeals and beneficiary complaint reviews, outreach initiatives, and advocacy services are how Acentra Health continues to play a critical role in strengthening patient protections and improving care outcomes within the Medicare system.

Appeals Update

Acentra Health has identified an increase in medical records being uploaded to incorrect case identification (ID) numbers. To help prevent processing delays, please carefully verify the case ID number before submitting any medical records. Uploading records to the wrong case can result in:

• Delays in the appeal review process
• Medical records not being associated with the correct appeal
• Appeals being closed in favor of the beneficiary due to missing medical records

Taking a moment to confirm the correct case ID before submission will help ensure appeals are processed accurately and timely.

As a reminder, Acentra Health does not make phone calls to notify providers when an appeal has been initiated or when a determination has been made. These notifications are sent directly to your facility via fax.

To ensure you continue receiving appeal notifications and determination letters, please verify that your facility’s contact information and fax number are current. If you have recently made changes to your contact information or would simply like to confirm that the information on file is correct, please visit www.acentraqio.com and update your records.

To update your information:

• Visit www.acentraqio.com
• Select “Healthcare Providers” in the top menu bar
• Navigate to “Update Your Contact Information” in the dropdown menu

Keeping your contact information up to date helps ensure timely receipt of appeal-related communications and prevents delays in receiving important notifications and determination letters.

Acentra Health Resources - July Podcast

Our July podcast, Protecting Your Skilled Nursing Facility Benefits: What Every Medicare Beneficiary Should Know, is now available on both Apple Podcasts and YouTube. This will provide valuable information for people who are receiving care in a skilled facility to better prepare for their eventual discharge.

Rural Health Updates

View the Rural Health Transformation (RHT) Program project abstracts submitted by each state. As required by the funding opportunity, each state provided a one-page overview of its proposed project, including its goals and expected results, to help inform the public.

Feedback

We value your feedback. Please let us know if there is any content that you would like to see covered in our stakeholder/provider newsletter by emailing QIOCommunications@acentra.com.