If you want to communicate BFCC-QIO information, please email Acentra Health at QIOCommunications@acentra.com and request a newsletter insert or fact sheet for your organization. Please do not copy and paste information from Case Review Connections.

in this issue:

• Medical Director's Corner
• Appeals Update
• Rural-Urban Disparities in Health Care in Medicare
• CMS Quality Conference
• Resources to Help You Share Medicare Rights Information
• February Health Observance - American Heart Month
• March Health Observance - Patient Safety Awareness Week
• Feedback
• SNF Criteria Podcast

medical director's corner - jessica whitley, md, mba

Navigating the Medicare Beneficiary Appeals Process with the BFCC-QIO

The Medicare beneficiary appeals process is a crucial safeguard ensuring that individuals receive the care they need. Understanding the role of the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) can help post-acute care providers better support beneficiaries in navigating this process.

Significant Increase in Appeals Volume

Since August 2019, there has been a striking 198 percent increase in the volume of appeals. This rise is particularly noteworthy given that the total Medicare beneficiary population has grown by only 10 percent in the same period. The overwhelming majority of these appeals originate from skilled nursing facilities (SNFs).

Medicare Advantage Plans and Appeals Trends

• Of the appeals coming from SNF settings, 89% come from beneficiaries enrolled in Medicare Advantage (MA) plans, despite an MA penetration of 51%.
• MA plans also have a higher proportion of repeat appeals. In Contract Year 1, Quarter 3 (November 2024 - January 2025), 26 percent of MA plan appeals were repeat appeals compared to 10 percent for Fee-for-Service (FFS) beneficiaries. This suggests a recurring disagreement over Medicare coverage decisions with MA plans.
• FFS plans generally show lower repeat appeal rates, indicating fewer disputes over coverage decisions. No significant variation has been observed between the last three quarters.

Length of Stay Disparities

In Quarter 3, FFS beneficiaries continued to have a significantly higher average length of stay compared to those in MA plans, 39 versus 26 days. This trend has remained stable across quarters.

Common Diagnoses Among Beneficiaries Filing Appeals

The predominant diagnoses among beneficiaries filing appeals from SNFs include:

• Infections
• Falls
• Generalized Weakness
• Lower Extremity Injuries

These diagnoses accounted for 63 percent of all appeals in Quarter 3.

Mobility Impairments and the NOMNC

Data analysis indicates that beneficiaries often have significant mobility impairments when they receive a Notice of Medicare Non-Coverage (NOMNC). Furthermore, mobility is further impaired when beneficiaries receive a repeat NOMNC during the same SNF stay.

Provider Responsibilities in the Appeals Process

As a post-acute care provider, you play a vital role in supporting beneficiaries by:

• Ensuring patients receive the NOMNC as required.
• Educating patients and families about their rights to appeal.
• Cooperating with BFCC-QIO requests for medical records and information. Make sure your contact information is updated.
• Engaging in transparent communication with beneficiaries about care transitions and discharge planning.

Recommendations for Skilled Nursing Facilities to Improve Medical Record Documentation

To enhance medical record documentation and support accurate beneficiary care, SNFs should:

• Ensure Clinical Documentation Reflects Current Clinical Condition: Regularly update medical records to reflect the beneficiary’s present health status, including any acute changes.
• Maintain Clear and Updated Goals: Include clear documentation of current treatment and rehabilitation goals as well as highlight any changes or updates to these goals.
• Track and Document Goal Modifications: Clearly indicate when goals have been modified, including the rationale for the changes and any new interventions implemented.
• Establish and Document Maintenance Programs: Ensure records include details about the establishment of maintenance programs to prevent functional decline and maintain stability.
• Include Beneficiary and Caregiver Training Information: Document all training provided to the beneficiary and/or caregiver, including education on disease management, mobility support, and discharge planning.
• Enhance Consistency Across Care Teams: Foster communication among interdisciplinary team members to ensure documentation remains consistent and reflective of the care provided.

By working together, post-acute care providers and the BFCC-QIO can protect beneficiary rights and ensure that Medicare beneficiaries receive appropriate, high-quality care.

appeals update

The Office of Management and Budget (OMB) has approved revised versions of the Notice of Medicare Non-Coverage (NOMNC / CMS-10123) and the Detailed Explanation of Non-Coverage (DENC / CMS-10124).

• Providers should use the revised NOMNC for both Original Medicare and Medicare Advantage starting January 1, 2025.
• Providers must also use the revised DENC for Original Medicare starting January 1, 2025. For Medicare Advantage, there is an extended deadline for implementing the revised DENC.
• Acentra Health will continue to accept the previous version of the NOMNC without making it invalid.

The updated notices, including Spanish versions, are available by going to www.cms.gov/bni and choosing FFS & MA NOMNC/DENC.

You can also watch a YouTube video, Notice of Non-coverage Form: Learn How to Fill Out the New Form, with instructions about filling out the new form.

rural-urban disparities in health care in medicare

This November 2024 report provides a nationwide summary of the quality of health care received by Medicare beneficiaries. It is divided into three sections: (1) rural-urban differences in healthcare experiences and clinical care; (2) variations in these differences by race and ethnicity; and (3) historical trends in quality of care for rural and urban residents. The first two sections focus on quality-of-care data reported in 2023 while the third section examines trends using data from 2017 to 2023.

cms quality conference 

The CMS Quality Conference will be held March 17-19, 2025, in Baltimore, Maryland, in person or virtually. This year's theme is Elevating Quality - Advancing Optimal Health for Individuals, Families, Caregivers, Clinicians, and Communities. You can learn more about:

• Collecting and Using Quality Data – Leveraging data to drive better healthcare outcomes.
• Collaborating with Partners and Communities – Strengthening relationships for collective impact.
• Understanding Patient and Caregiver Perspectives – Ensuring voices are heard and needs are met.
• New Technology and Innovations – Exploring advancements that transform health care.

Registration is now available.

resources to help you share medicare rights information

Visit our Advocacy Resources page for materials to help you share Medicare rights information with Medicare beneficiaries in your community.

One example of materials available is flyers, which are available in both English and Spanish. This flyer includes information about Acentra Health's free services for people who have Medicare.

february health observance - american heart month

February is the month when we focus on heart health. Visit our American Heart Month page for information that you can share with your patients and communities.

march health observance - patient safety awareness week

Patient Safety Awareness Week is observed from March 9 to March 15, 2025. This brings an opportunity to raise awareness about patient safety issues and recognize staff for the completion of successful projects. The Institute for Healthcare Improvement has information and resources available, including a webinar on Diagnostic Excellence.

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.

Publication No. R146810-127-2/2025. This material was prepared by Acentra Health, a Medicare Quality Improvement Organization under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.