About the BFCC-AIRR
The Beneficiary and Family Centered Care Audit and Inter-Rater Reliability Review (BFCC-AIRR) provides expert healthcare quality improvement (QI) services for Inter-Rater Reliability (IRR) of beneficiary-requested appeals and claims review to support the BFCC provisions of the Medicare Quality Improvement Organization (QIO) Program.
The work of the BFCC-AIRR aligns with and supports the CMS National Quality Strategy to advance toward a more equitable, safe, and outcomes-based healthcare system for all individuals, and is part of CMS’ overall strategy to evaluate programs in the 13th Scope of Work by providing better linkages between the BFCC-QIO and the QIN-QIO activities. (Figure 1).
Specifically, the BFCC-AIRR:
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Supports measurable improvements in the quality of health care for Medicare beneficiaries.
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Supports an effective and impactful evaluation by ensuring that there is accuracy and consistency in beneficiary appeals and claims review disposition decisions by the BFCC QIN-QIOs. A direct impact on ensuring high-quality care.
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Enhances patient safety through medical record reviews for preventable patient safety events and the quality of care provided.
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Supports an overall strategy for data-driven learning healthcare system for quality improvement.
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Safety valve to ensure that Medicare beneficiaries can exercise their right to high-quality healthcare
The BFCC-AIRR also supports CMS’ overall evaluation of the QIO program’s performance by providing valid data to assess the impact of BFCC-QIO review activities on ROI and quality.
Inter-Rater Reliability Reviews
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Inter-rater reliability (IRR) refers to the reproducibility or consistency of decisions between two reviewers. The goal of IRR reviews is to ensure consistency in decision-making between the QIOs and the BFCC-AIRR, thus improving consistency in beneficiary appeals and claims review disposition decisions leading to improved quality of healthcare for Medicare beneficiaries. The BFCC-AIRR conducts 2,500 IRR reviews annually for each of the following appeal types:
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Medicare Fee-for-Service (FFS) Post-Acute Appeals (formerly referred to as BIPA Appeals)
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Medicare Advantage (MA) Post-Acute Appeals (formerly referred to as Grijalva Appeals)
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Hospital Discharge Appeals (formerly referred to as Weichardt Appeals)
The BFCC-AIRR also performs 2,500 annual reviews of Part A Short Stay claims.
If the BFCC-AIRR disagrees with QIO’s review decision, these findings are sent to the BFCC-QIO. The BFCC-QIO will review the AIRR’s findings and can initiate the rebuttal process (Figure 2 below) if they disagree with the IRR findings. CMS may convene discussion sessions between the BFCC-AIRR and BFCC-QIO(s) in non-concurrent cases to promote collaboration, communication, and consistency across case and claims reviews. If there is still a disagreement after both parties have met and discussed the reviews, CMS will determine the disposition of deadlocked cases.
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Figure 2. AIRR Rebuttal Process
To promote better linkages between the BFCC-QIO and the QIN-QIO program activities, data and key findings generated from the BFCC-QIO / AIRR IRR process will be shared with other CMS 13th SOW support contractors such as the Program Monitoring and Evaluation Contractor (PMEC) or National Learning Center Contractor (NLCC).