Knowledge Base Article

What is a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)?

“A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the quality of care delivered to people with Medicare…BFCC-QIOs help Medicare beneficiaries exercise their right to high-quality health care. 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 health care 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 ten regions.”¹

Who are the BFCC-QIOs?

Kepro and Livanta are the two contractors that serve as the BFCC-QIOs for all fifty states and three territories, which are grouped into ten regions.

Kepro

Region 1: Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, Vermont

Region 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

Region 6: Arkansas, Louisiana, New Mexico, Oklahoma, Texas

Region 8: Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

Region 10: Alaska, Idaho, Oregon, Washington

Livanta

Region 2: New Jersey, New York, Puerto Rico, U.S. Virgin Islands

Region 3: Delaware, Maryland, Pennsylvania, Virginia, West Virginia, Washington D.C.

Region 5: Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

Region 7: Iowa, Kansas, Missouri, Nebraska

Region 9: Arizona, California, Hawaii, Nevada, Pacific Territories

BFCC-QIO 2023 Annual Reports

In late February, Kepro and Livanta released their Annual Medical Services Review Reports for 2023 which includes data for claims with dates of service from January 1, 2023 through October 31, 2023.

Livanta noted in their March 5^th edition of The Livanta Compass, that they prepare “a report for each of the five regions it serves, highlighting data points and the accomplishments of each specific region. Although each report is tailored to a particular region, the processes and individuals who safeguard the rights of Medicare beneficiaries remain consistent across all the regions that Livanta serves.”

Each report includes data at the region and state level.

The data in Table 6 (Beneficiary Appeals of Provider Discharge/Service Termination and Denials of Hospital Admission Outcomes by Notification Type) in the annual reports includes the number of appeal reviews and percentage of reviews for each outcome in which the peer reviewer either agreed or disagreed with the hospital discharge or discontinuation of skilled services. The following Appeals Notification Types are included in table 6:  

• Notice of Non-coverage Fee-for-Service (FFS) Preadmission/Admission – Admission and Preadmission/HINN 1,
• Notice of Non-coverage Request for BFCC-QIO Concurrence - HINN 10,
• Medicare Advantage Appeal Review for Comprehensive Outpatient Rehabilitation Facilities (CORFs), Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Value-Based Insurance Design (VBID) Model Hospice Benefit Component – Grijalva,
• FFS Expedited Appeal (CORF, HHA, Hospice, SNF) – BIPA,
• Notice of Non-coverage Hospital Discharge Notice – Attending Physician Concurs (FFS hospital discharge), and
• MA Notice of Non-coverage Hospital Discharge Notice – Attending Physician Concurs (MA hospital discharge).

Collectively, for all the above appeals in all ten regions, the total number of reviews in 2023 was 266,449 with a Peer Reviewer agreeing with the discharge 72.827% of the time. Following are the collective findings for all ten regions for Medicare FFS and Medicare Advantage beneficiary appeals in the hospital setting.  

HINN 1

Total Number of Reviews: 239

Percent of time the Peer Reviewer Agreed with the Discharge: 73.066%

HINN 10

Total Number of Reviews: 108

Percent of time the Peer Reviewer Agreed with the Discharge: 76.619%

Notice of Non-Coverage Hospital Discharge Notice – Attending Physician Concurs (FFS Hospital Discharge)

Total Number of Reviews: 25,523

Percent of time the Peer Reviewer Agreed with the Discharge: 89.933%

Notice of Non-Coverage Hospital Discharge Notice – Attending Physician Concurs (MA Hospital Discharge)

Total Number of Reviews: 23,923

Percent of time the Peer Reviewer Agreed with the Discharge: 89.799%

Examples of what else you will find in the annual reports:

• The types of evidence or standards of care that were used to support Review Analysts’ assessments,
• Quality of care concerns and quality improvement initiatives, and
• Information about immediate advocacy cases and example success stories.

Where to Access the 2023 Annual Reports

I encourage you to review your Region’s Annual Report and share it with key stakeholders (i.e., Case Management, Social Workers). The reports are available at the following links:

• Kepro: https://www.keproqio.com/aboutus#annualreports
• Livanta: https://www.livantaqio.cms.gov/en/About/Annual_Report

Resource

¹CMS QIO webpage: https://www.cms.gov/medicare/quality/quality-improvement-organizations