Physician Reviewer Training:
Introduction & Overview
Sharon Hoffarth, MD, MPH, FACPM
Chief Medical Officer
Publication MO-13-05-CR
This 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
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
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
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
Medicare Case Review Process
Publication MO-13-05-CR
This 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 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
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
Case Review by Nurse
Case Review
Process Algorithm
NO
YES
NO
Refer?
QIO PR
Review
Close
Case
YES
Issue?
Close
Case
Send Letter to
Provider/Physician
Final
Letter?
NO
YES
Close
Case
Await Response
(15-20 Days)
NO
Response
Received?
Send Final
Letter
YES
YES
Physician &/or
Provider Agree?
NO
QIO PR
Close
Case
Send Final
Letter
Review
Send Final
Letter
Close
Case
Close
Case
Case Review
Process Algorithm
Case Review by Nurse
YES
QIO PR
Review
Refer?
NO
Close
Case
Case Review
Process Algorithm
YES
QIO PR
Review
NO
Close
Case
Issue?
YES
Send letter to
Provider
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 Review
Process Algorithm
YES
Send letter to
Provider/Physician
NO
Await Response
(15-20 Days)
Final
Letter?
YES
Close
Case
Case Review
Process Algorithm
Final
Letter?
NO
Await Response
(15-20 Days)
NO
Send Final
Letter
Close
Case
Response
Received?
YES
Physician &
Hospital Agree?
Case Review
Process Algorithm
Response
Received?
YES
Send Final
Letter
YES
Physician &/or
Provider Agree?
NO
QIO PR
Review
Send Final
Letter
Close
Case
Close
Case
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