KEPRO Updates

on Tuesday, 06 March 2018. All News Items | Case Management | Quality | Documentation

2018 Winter e-Newsletters, Get to Know KEPRO Webcast & KEPRO Annual Reports

KEPRO, the Beneficiary and Family Centered Care QIO (BFCC-QIO) for more than 30 states releases a quarterly e-newsletter called Case Review Connections. They provide a separate newsletter for acute care providers and post-acute care providers. KEPRO released the 2018 Winter Editions of their e-newsletters on February 21, 2018.

Acute Care Edition:

Post-acute Care Providers:

You can sign up to receive newsletters on the KEPRO website at

Get to Know KEPRO Your BFCC-QIO Webcast: March 14, 2018

Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M is hosting a “Get to Know KEPRO BFCC-QIO” webcast on March 14, 2018 at 10 am ET. During this webcast you will learn more about the services that they offer to Medicare beneficiaries and their families concerning beneficiary complaints, discharge appeals and immediate advocacy.

The webcast is 1 hour long. You can sign up to participate through Palmetto’s Event Registration Portal. Event Registration Portal.

KEPRO Annual Reports

In the winter newsletters, KEPRO announced the release of their Annual Reports for each of their BFCC-QIO Area’s (2, 3 and 4). “These reports provide data regarding the number of reviews, the top 10 medical diagnoses, review settings, quality of care concerns confirmed as well as their corresponding quality improvement initiatives, and information about discharge and service terminations.” Links to the reports are at the bottom of the About Us page on KEPRO’s website.

Evidence Used in Decision Making: Quality of Care & Medical Necessity Reviews

The Annual Reports include a table describing the types of evidence or standards of care used to support KEPRO Review Analysts’ assessments and aid in formatting questions raised to the Peer Reviewer for Medical Necessity/Utilization Review and Appeals and Quality of Care Reviews.

Quality of Care

It was interesting to find that for Quality of Care reviews for Sepsis, KEPRO sites the Institute for Health Care Improvement (IHI) sepsis indicators and guidelines for the identification and treatment of sepsis. The IHI appears to follow the Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. This guidance defines sepsis as “a systemic, deleterious host response to infection leading to severe sepsis (acute organ dysfunction secondary to documented or suspected infection) and septic shock (severe sepsis plus hypotension not reversed with fluid resuscitation.)”

The 2012 guidelines are more in-line with the CMS’s Hospital Inpatient Quality reporting severe sepsis management measure (SEP-1). However, they are out of sync with the Sepsis-3 definition published in JAMA February 2016 that defines sepsis as a life threatening organ dysfunction cause by a dysregulated host response to infection (confirmed or suspected). Of note, the Surviving Sepsis Campaign adopted the Sepsis-3 definition in March 2017.

In all three KEPRO areas, sepsis was the top medical diagnosis associated with Medicare claims. Here at MMP we have been hearing from several of our clients that they are receiving denials from Commercial payers and Medicare Advantage Plans who have also adopted the Sepsis-3 definition. We are closely following Medicare review contractor activity as we believe sepsis cases targeted for medical necessity are on the rise. We will keep you posted.

Medical Necessity & Appeals

Following is an excerpt from the table detailing the evidence/standards of care used by KEPRO for Medical Necessity Reviews and Appeals.

Review TypeDiagnostic CategoriesEvidence/Standards of Care UsedRationale for Evidence/Standard of Care Selected
Medical Necessity/ Utilization Review InterQual® & CMS’ Two-Midnight Rule Benchmark Criteria InterQual® & CMS’ Two-Midnight Rule Benchmark Criteria InterQual® - Assess the safest and most efficient care level based on severity of illness, comorbidities and complications, and the intensity of services being delivered. Its criteria cover more than 95% of admission reasons for any level of care. Under the final CMS Two-Midnight Rule, surgical procedures, diagnostic tests, and other treatments (in addition to services designated as inpatient-only) are generally appropriate for inpatient hospital admission and payment under Medicare Part A when the physician expects the beneficiary to require a stay that crosses at least two midnights and admits the beneficiary to the hospital based upon that expectation.
Appeals   National Coverage Determination Guidelines; JIMMO settlement language and guidelines; and InterQual® and CMS’ Two Midnight Rule Benchmark Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National Coverage Determinations (NCDs) are made through an evidence-based process.
Source: KEPRO, Area 3 Annual Medical Services Report at

MMP recommends visiting KEPRO's website to learn about who they are and the services they provide.

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc.  Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. 

In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Risk Assessment (CRA) Tool. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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