Physician Reviewer Training: Introduction & Overview

1. Physician Reviewer Training:Introduction & Overview Sharon Hoffarth, MD, MPH, FACPM Chief Medical Officer

2. 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

3. Physician Reviewers – Benefits of being a PR • Respect of other physicians and providers • Case review performed by physicians helps to maintain physician autonomy • Educational • Prorated hourly reimbursement

4. Physician Reviewers -- Expectations • Commitment to quality & excellence • Knowledgeable about various settings of care • Flexible, willing to be called on short notice

5. 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

6. 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

7. 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

8. 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

9. 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

10. Medicare Case Review Process

11. 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)

12. 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

13. 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

14. 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

15. 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

16. Case review process • 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

17. Send Letter to Provider/Physician Final Letter? Close Case Await Response (15-20 Days) Response Received? Send Final Letter Case Review by Nurse Case Review Process Algorithm YES NO Refer? QIO PR Close Review Case NO YES Issue? Close Case NO YES NO YES YES NO Physician &/or Provider Agree? QIO PR Send Final Close Review Letter Case Send Final Letter Close Close Case Case

18. Case Review Process Algorithm Case Review by Nurse Refer? YES NO QIO PR Review Close Case

19. Case Review Process Algorithm YES QIO PR Review Issue? NO YES Close Case Send letter to Provider

20. 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?

21. Case Review Process Algorithm YES Send letter to Provider/Physician Final Letter? NO YES Close Case Await Response (15-20 Days)

22. Case Review Process Algorithm Final Letter? NO Await Response (15-20 Days) Response Received? NO YES Physician & Hospital Agree? Send Final Letter Close Case

23. Case Review Process Algorithm Response Received? YES Physician &/or Provider Agree? YES NO QIO PR Review Send Final Letter Send Final Letter Close Case Close Case

24. 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

25. 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

26. 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

27. 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

28. Internal quality control • Principles of utilization management • Credentialing policies & procedures • Conflict of interest • Verification of peer status on case-by-case basis

29. 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

30. 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

31. 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?

32. For questions and additional information, call Rita Ketterlin at 1-800-735-6776, ext. 153