physician reviewer training: introduction & overview
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Publication MO-13-05-CRThis material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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
Physician Reviewer Training:Introduction & Overview
Sharon Hoffarth, MD, MPH, FACPM
Chief Medical Officer
Objectives
• Understand Physician Reviewer (PR)
eligibility requirements
• Understand Primaris’ internal case review
process
• Become familiar with the Physician Reviewer
case review form and the written review
process
• Respect of other physicians and providers
• Case review performed by physicians helps to
maintain physician autonomy
• Educational
• Prorated hourly reimbursement
Physician Reviewers – Benefits of being a PR
Physician Reviewers -- Expectations
• Commitment to quality & excellence
• Knowledgeable about various settings of
care
• Flexible, willing to be called on short notice
Physician Reviewers - Credentialing requirements
• Active, unrestricted Missouri medical license
• Active staff privileges
• Board certification or board eligibility
• Initial case review training
• Confidentiality statement
• Active Practice
− Care for and treat Medicare patients > 20
hrs/week
Clinical Case Review Philosophy
• Collegial clinical discourse with advice and
feedback
• Assist the healthcare community in
improving patient care
• Role is supportive, not punitive
• Based on reasoned medical opinion
− Clinical judgment; not UR based
− Evidence-based, professionally-recognized
standards of care
− May be more than one valid approach to a clinical
issue
Help!
• Primaris toll free line (800) 735-6776
• Carmen Woodward, ext. 124 for Appeals
reviews
• Rita Ketterlin, ext. 153 for HW-DRG, UR,
Quality of Care, and EMTALA reviews
• Case-related questions
− Call the nurse reviewer identified in packet
• Primaris
– 200 North Keene St, Suite 101, Columbia, MO
65201
How to contact Primaris – Electronic communication
• www.primaris.org
• FirstInitialLastname@primaris.org
− e.g., shoffarth@primaris.org
• Email is NOT secure
− Do NOT use Primaris e-mail for case-specific
communication or for information with
patient, practitioner or provider identifiers
Primaris - Origins
• Originally we were the Missouri Patient Care
Review Foundation (MissouriPRO)
− Founded by MSMA & MAOPS 1983; began operations
in 1984
− Awarded the CMS peer review contract for Missouri
• CMS focus expanded in the 90’s to include
healthcare quality improvement
• Current CMS QIO work includes clinical case review and
quality improvement projects with Missouri physicians
and providers
-- In 2004 we changed our name to Primaris to reflect
our expanded scope of work
Publication MO-13-05-CRThis material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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
Medicare Case Review Process
Physician Reviewer Responsibilities – Potential Conflicts of Interest: avoid
• Participated in any aspect of the care under
review
• Financial interest related to the case or provider
• Related to patient, either kin or acquaintance
• Business or referral relationship with physician
or provider
• Physician or provider may be a competitor
(almost always implied with geographic
proximity)
Physician Reviewer Responsibilities --Confidentiality
• HIPAA
• Medical records = confidential information
− Locked and out of sight if in a vehicle
− Must be secured: safely locked in office/home
− Lost packets & records
• Do NOT discuss with colleagues
• Email is NOT secure and should not contain
any patient, practitioner or provider names
or identities
Physician Responsibilities –Practical considerations
• Notify office staff of PR status
• Designate an office contact
• Primaris staff will call the contact prior to
sending packet
• Once packet arrives, the PR should review
promptly
Clinical Review Process – Case categories
• Majority of reviews are:
− Medical necessity
− HW-DRG validation
− Discharge appeals (hospital, SNF, home health, hospice,
acute rehab)
− Quality of Care
− EMTALA
• Uncommon
− Invasive procedure necessity
− Length of stay
Sources of Requests for Review
• Beneficiary complaint
• Immediate notices/appeals
• Hospital request for higher weighted DRG
changes
• Federal/State agency referral
− FI/Carrier/MAC referral
• Anti-dumping (EMTALA)
• Assistant at cataract surgery
• Non-Physician Reviewer (NPR) examines
case
− Typically RN, LPN, or Coding professional
-- If a UR case, NPR applies InterQual
screens/criteria
• If the NPR cannot approve, case must be
referred to a PR
• PR specialty and practice setting match
• If the PR renders an adverse determination,
the NPR will send a denial or a notification
letter that includes an opportunity to
appeal/opportunity for improvement, as
appropriate, to providers
Case review process
Case Review by Nurse
Refer?
CloseCase
QIO PRReview
Issue?
Send Letter toProvider/Physician
FinalLetter?
CloseCase
Send FinalLetter
Await Response(15-20 Days)
ResponseReceived?
CloseCase
Send FinalLetter
CloseCase
Send FinalLetter
CloseCase
QIO PR
Review
NOYES
YES NO
NO YES
NO YES
YESNO
Case ReviewProcess Algorithm
Physician &/or Provider Agree?
Close Case
Case Review by Nurse
QIO PR Review
CloseCase
Refer?YES NO
Case Review Process Algorithm
Case ReviewProcess Algorithm
QIO PR Review
Issue?
Send letter to Provider
CloseCase
YES
NO YES
Clinical Review Due Process – Requesting additional information after denial at first level
• Information gathering approach
• Was there additional information available to
provider that was not part of the
documentation submitted for the initial
review?
Case ReviewProcess Algorithm
FinalLetter?
CloseCase
Await Response (15-20 Days)
Send letter to Provider/Physician
YES
YESNO
Case ReviewProcess Algorithm
ResponseReceived?
FinalLetter?
Physician & Hospital Agree?Send Final
Letter
CloseCase
Await Response (15-20 Days)
NO
NO YES
Case ReviewProcess Algorithm
Physician &/orProvider Agree?
ResponseReceived?
QIO PR ReviewSend Final
Letter Send Final Letter
CloseCase
CloseCase
YES
YES NO
Re-Review
• Provider request for re-review
− 30 days
− Additional info not required
• Send to PR
− Not previously worked case
− Board certified/board eligible
• PR decision options
− Uphold previous decision or reverse
Clinical Case Review –Physician reviewer worksheet
• On the form, the NPR provides
-- Brief case summary
-- Potential issues and questions for PR
• Ample space for PR notes, determinations, and
rationales
• PR must sign, date, enter time spent on review
• Answer all the PR questions and double check
answers
• Your signature required
-- Date of review
-- Time spent reviewing the case
Clinical Case Review –Physician reviewer worksheet
• For each NPR-listed concern, the PR must
enter a decision
-- The PR may list additional issues or concerns
• The PR must answer yes or no
(agree/disagree) for each issue
Clinical Case Review –Physician reviewer worksheet
• Each decision must have a rationale for the
decision,
-- Be specific and coherent
-- Avoid accusatory language or laying blame
• For Quality of Care cases:
-- Cite accepted, commonly recognized standards
-- Outline alternative methods of diagnosis,
treatment and management, as appropriate
-- Identify responsible provider, physician, or
other staff such as Nursing
Internal quality control
• Principles of utilization management
• Credentialing policies & procedures
• Conflict of interest
• Verification of peer status on case-by-case basis
Internal quality control
• URAC Accredited
− American Accreditation HealthCare Commission
• Inter-rater reliability audits
-- PRs and NPRs
-- Ensure consistency and accuracy in our reviews
− Identify opportunities for process improvement
− Identify education needs and areas for future
training
Common review errors
• Equivocal answers – no definite position taken or
issue at hand not really addressed
• Illegible
• Not all questions answered / incomplete
• Excessive turn around time
• Responsible party (provider/physician/ancillary
staff) not identified
Common review errors continued
• Citing irrelevant missing medical record
elements
• Considering info not available to the treating
physician at the time care was rendered
• Answering a question with a question
• Difference of opinion as basis for determination/
rationale
• Today’s environment of patient safety and QI
− Was adverse event preventable? Unpreventable?
− Was adverse event a known risk or acceptable
outcome?
For questions and additional information, call Rita Ketterlin at 1-800-735-6776, ext. 153
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