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HCAC & oppc Medicaid Inpatient Hospital settings April 2012 . Provider Preventable Conditions. Definitions.
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Definitions • Other provider-preventable condition (OPPC): A condition occurring in any health care setting that could have reasonably been prevented through the application of evidence based guidelines that meet the criteria established under 42 CFR part 447.26; Are defined to include at minimum, the three Medicare National Coverage Determinations (surgery on the wrong patient, wrong surgery on a patient, and wrong site surgery). • Health care acquired condition (HCAC): A condition occurring during an inpatient hospital stay, identified as a Medicare HAC, with the exception of deep vein thrombosis/pulmonary embolism related to total knee replacement or hip replacement in pediatric and obstetric patients. • Hospital-acquired condition (HAC): An undesirable condition occurring during an inpatient hospital stay. A list of conditions is identified in the Federal Register for Medicaid Regulations.
HCACs and OPPCs Effective Date May 1, 2012
Scope of Services • Review of HCACs & OPPCs that occur during hospitalizations • Post payment claim-based analysis • Reporting to the Medicaid agency
RESOURCES Federal Register For Medicaid Regulations http://www.gpo.gov/fdsys/pkg/FR-2011-06-06/pdf/2011-13819.pdf eQHealth http://fl.eqhs.org
HCACs & OPPCs Occurring During Hospitalizations Limit the number of days certified only to those preceding the event and any additional medically necessary inpatient days for services unrelated to the event
Post Payment Claims-based Analysis Verification of the degree of reliability between reporting and actual claims submission. • Comparison of the information submitted to eQHealth to the “present on admission” (POA) indicator and ICD-9-CM codes on the submitted claim.
Post Payment Claims-based Analysis Cont’d Upon identification of a discrepancy: • A request for an electronic copy of the medical record is sent via e-mail; the record is to be submitted within 30 days of the request. • Medical record received – review continues • Medical record not received • Review is suspended; and • AHCA is notified
Reporting Results to AHCA • Frequency of occurrence by: • Type of HCAC or wrong surgery/invasive procedure • Provider • Provider reporting reliability • Provider specific patterns
Review Process eQHealth is responsible for reviewing HCACs and OPPCs related to hospitalizations in all hospital settings.
Review Process • Provider reporting during submission of review requests • Identification by eQHealth during review
First Level Review When a HCAC or OPPC is reported by a provider or identified by a nurse reviewer, the following actions are taken: • Determine if additional information is needed: • No – Proceed with review • Yes – Request additional information • HCAC or wrong surgery/invasive procedure: • No – Proceed with review • Yes – Refer to second level physician reviewer
Second Level Review Process • The physician reviewer may: • Pend the request for additional information • Consult with the attending physician • Determinations: • HCAC or wrong surgery/invasive procedure • Whether inpatient days are solely for the treatment related to the incident
Adverse Determinations • Full Denial – • The incident occurred on the day of admission of the recipient to the hospital and care is solely for treatment related to the incident. • A recipient’s readmission (to the same hospital) occurs solely as a result of an incident related to a previous admission. • Partial Denial – Inpatient days following the occurrence are solely for the treatment related to the incident.
Reconsiderations • In accordance with Agency policy, any party involved in the case may request a reconsideration of an adverse determination. • Requests for reconsideration will be reviewed by a physician reviewer not involved in the original case review.
Provider Reporting Requirements - eQSuite • Providers must report the: • Date of the occurrence • Nature of the specific event • Applicable ICD-9-CM code
RESOURCES Customer Service 855-444-3747 Nancy Calvert Director, Provider Education & Outreach ncalvert@eqhs.org
