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Healthinsight to No Longer Conduct Medicare Coverage and Discharge Appeals, Quality of Care Reviews

KEPRO will Perform Reviews Starting August 1
Under a program reorganization, the Centers for Medicare & Medicaid (CMS) split the QIO’s core functions of quality improvement and beneficiary case review. Under the new program structure, an organization cannot perform both roles.

Beginning August 1, Ohio-based KEPRO will perform medical case review on behalf of New Mexico Medicare beneficiaries, a function currently performed by HealthInsight. KEPRO will continue to protect beneficiaries and strive to improve health care services for Medicare beneficiaries through beneficiary quality-of-care reviews, discharge and termination of service appeals, and other case review.

HealthInsight will continue to perform clinical reviews, including Medicare appeal reviews, through July 31. Cases in progress on July 31 will be transferred to KEPRO for completion.

What this transition means to hospitals, nursing homes and home health agencies:

  • Facilities will have a new contact at KEPRO for transmitting records and case information.
  • Effective August 1, 2014, facilities must include KEPRO’s contact information in documents you are required to give Medicare beneficiaries to inform them about their review rights, including Notices of Medicare Non-Coverage and any other print and electronic copies of beneficiary resources that currently include HealthInsight contact information
  • Your facility will need to update records review policies and procedures that contain HealthInsight contact information.
  • Contact information for KEPRO:

    5700 Lombardo Center Drive, Suite 100
    Seven Hills, OH 44131

    Toll-free: 844-430-9504
    Fax: 844-878-7921
    TTY users: 855-843-4776

    Please note: Numbers will not be functional until August 1, 2014.

    HealthInsight will continue to lead health care quality improvement activities for the Medicare Program in Utah under a five-year contract awarded by the Centers for Medicare & Medicaid Services (CMS). On July 18, 2014, HealthInsight became the Quality Innovation Network – Quality Improvement Organization (QIN-QIO) for Nevada, New Mexico, Oregon and Utah for a contract term extending through July 2019. New quality improvement initiatives will be underway in the next few months that include work with health care professionals in all settings of care.