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12 Protection of Medicare Beneficiaries and Program Integrity
Pages 297-324

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From page 297...
... 12 Protection of Medicare Beneficiaries and Program Integrity CHAPTER SUMMARY This chapter discusses the case review activities that were under taken by Quality Improvement Organizations (QIOs) during the 7th scope of work (SOW)
From page 298...
... 298 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM QIOs helped maintain the integrity of the Medicare program by performing specific reviews related to utilization concerns, including hospital admissions and coding, to ensure that the reimbursed services were necessary and appropriate. Earlier cycles of the QIO program focused on case review, but this was primarily carried out only in the hospital inpatient setting and for fewer categories of cases.
From page 299...
... PROTECTION OF BENEFICIARIES AND PROGRAM INTEGRITY 299 TABLE 12.1 Types of Reviews for Each Mandated Category of Review Category of Review Type of Review Provider Setting Beneficiary complaints Quality review All settings except nursing homes (which are addressed by the state survey agency) Potential EMTALA Quality review Hospitals violations (patient dumping)
From page 300...
... 300 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM Categories of Case Reviews The following are the required categories of case review that QIOs performed (CMS, 2002, 2004b)
From page 301...
... PROTECTION OF BENEFICIARIES AND PROGRAM INTEGRITY 301 received notice from the managed care organization that the services provided by a skilled nursing facility, a home health agency, or a comprehensive outpatient rehabilitation facility were being terminated. The managed care organization must issue a notice of Medicare noncoverage (also referred to as an advanced notice)
From page 302...
... 302 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM Quality Reviews Quality reviews assess whether the health care delivered to beneficiaries met professionally recognized standards, was provided economically, was medically necessary, and was supported by adequate documentation. QIOs performed quality reviews for cases of both fee-for-service and managed care beneficiaries, but managed care cases were assessed only on the basis of the appropriateness of the services provided and the setting in which they were provided and not on the basis of medical necessity.
From page 303...
... PROTECTION OF BENEFICIARIES AND PROGRAM INTEGRITY 303 · Outlier reviews, · Limitation on liability determinations, · Readmission reviews, · Transfer reviews, · Circumvention of prospective payment system reviews, and · On-site reviews. Review Process QIOs conducted the reviews described above with the assistance of contracted reviewers who met specified requirements (CMS, 2004b)
From page 304...
... 304 Judge. Law on on QIO logs logs reviews case notifies and decision End SDPS SDPS QIO QIO ALJ ALJ of decision decision CMS Days*
From page 305...
... PROTECTION OF BENEFICIARIES AND PROGRAM INTEGRITY 305 A second screening review is performed after any missing documentation is provided. First Physician Review In the first physician review, a physician reviewer determines whether the concerns of the nonphysician reviewer are valid and if other concerns not previously identified exist.
From page 306...
... 306 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM · No reason for the pattern is found, · The provider has already found the problem and taken action, · The pattern for the case is the same as a pattern already identified and acted upon, or · The physician is no longer in practice. Other options are used when the provider is unwilling to formulate a plan or fails to complete the plan satisfactorily.
From page 307...
... PROTECTION OF BENEFICIARIES AND PROGRAM INTEGRITY 307 · Refer the case to the Office of the Inspector General of DHHS for sanctions. Sanctions can include a period of exclusion from the Medicare program (for a minimum of 1 year)
From page 308...
... 308 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM the care could have been better. Cases falling into the former designation were deemed appropriate for mediation.
From page 309...
... PROTECTION OF BENEFICIARIES AND PROGRAM INTEGRITY 309 BOX 12.2 Fast-Track Appeals Process "Step 1: A beneficiary or his or her representative receives a Notifi cation of Medicare Non-Coverage from a health care provider advising of an effective date when coverage for services will end, along with the beneficiary's appeal rights. Step 2: By noon of the day before the effective date that Medicare coverage ends, the beneficiary or his or her representative calls Lumetra and requests an appeal.
From page 310...
... 310 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM QIO PERFORMANCE EVALUATION IN THE 7TH SOW In the 7th SOW, CMS based a QIO's success in performing protection activities on: · Daily updates of activities in CRIS; · Development and implementation of a mediation plan; · Reporting on improvement plan activities; · Completion of beneficiary satisfaction surveys (after completion of the complaint process) ; · Collection of various contracts, reports, and other documents; · The timeliness of review completion (reviews should be completed within the designated time frames at least 90 percent of the time)
From page 311...
... PROTECTION OF BENEFICIARIES AND PROGRAM INTEGRITY 311 · Timeliness for all Task 3a reviews (24 points) , · Beneficiary satisfaction with the complaint process (21 points)
From page 312...
... 312 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM the 6th SOW of the QIO program, CMS addressed improper payments through utilization review and by the addition of the Payment Error Prevention Program. In the 7th SOW, the QIOs participated in HPMP, the successor to the Payment Error Prevention Program.
From page 313...
... PROTECTION OF BENEFICIARIES AND PROGRAM INTEGRITY 313 QIOs implemented these improvement plans in the same manner as they implemented the quality improvement projects under their technical assistance duties. QIOs developed plans to target specific providers or topic areas and created project plans describing the background, purpose, and goals of the project, including what indicators and calculations were to be used to evaluate a hospital's success.
From page 314...
... 314 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM TABLE 12.3 Texas 1-Day-Stay and Other Statewide Statistics for All DRGs Number of Total Percent DRG Discharges after Number of 1-Day Code DRG Description 1-Day Stay Discharges Stays 005 Extracranial vascular procedures 2,231 6,971 32.00 006 Carpal tunnel release 13 25 52.00 066 Epistaxis 91 369 24.66 134 Hypertension 942 4,368 21.57 NOTE: The 1-day-stay count excludes deaths, transfers, and patients leaving against medical advice. Data are for all prospective payment system inpatient hospitals (n = 340)
From page 315...
... PROTECTION OF BENEFICIARIES AND PROGRAM INTEGRITY 315 7th SOW (CMS, 2002)
From page 316...
... 316 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM BOX 12.3 Texas Medical Foundation One-Day-Stay Project "Details According to analysis performed by the Texas Medical Foundation (TMF) , there was a 51 percent increase in one-day stay discharges be tween fiscal year (FY)
From page 317...
... PROTECTION OF BENEFICIARIES AND PROGRAM INTEGRITY 317 "TMF is requesting that all hospitals: · Analyze comparative data related to the project indicator provided by TMF as well as one-day stay data provided periodically by TMF in the Program for Evaluating Payment Patterns Electronic Report (PEPPER) to determine if problems might exist.
From page 318...
... 318 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM the QIO loses 2 points. The QIO will receive an excellent pass for attaining 7 or more points, a full pass for 6 points, a conditional pass for 5 points, and a not pass for a score of 4 points or less (CMS, 2005b)
From page 319...
... PROTECTION OF BENEFICIARIES AND PROGRAM INTEGRITY 319 ability to protect beneficiaries and identify systemic quality problems. They strongly expressed their feelings about the need to keep case review as part of their repertoire and about the direct connections to quality improvement work: · "Quality improvement is often predicated on the [basis of the]
From page 320...
... 320 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM In all complaint cases, regardless of the use of mediation, the QIOs surveyed beneficiaries on their satisfaction with the complaint review process. This survey was implemented nationally in April 2003.
From page 321...
... PROTECTION OF BENEFICIARIES AND PROGRAM INTEGRITY 321 TABLE 12.4 Trends for National Weighted Payment Error Rates Period Error Rate (percent) FY 2001 4.7 FY 2002 4.82 FY 2003 (overall)
From page 322...
... 322 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM The remainder of the CEOs (9 of 15) said that that payment error reviews are definitely useful to quality improvement by providing leverage, enhanced access to provider staff for educational interventions, and monetary savings to Medicare.
From page 323...
... PROTECTION OF BENEFICIARIES AND PROGRAM INTEGRITY 323 are punitive organizations. Despite this perception, many QIOs argue that the dual roles can be synergistic.
From page 324...
... 2005d. Update on Statewide Percentiles for PEPPER 3 Measures Through Fourth Quarter, FY2003 (July­September 2003)

Key Terms

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