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