Attachment_J.3-C_TO_0002_Evaluation_Measures_Table.docx
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- BFCC-QIO IDIQ Federal contract opportunity
- Solicitation number
- 75FCMC18R0034
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J.3-C Case Review Evaluation Measures Table
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Attachment J.3-C Evaluation Measures Table Annual and 54th Month Evaluation Criteria Measures
BFCC Aim 2 Task Order: Beneficiary Protection- Case Review Services
Achieve 95% compliance with CMS requirements for Memorandums of Agreement and Physician Acknowledgement Statements over the contract period of performance.
Meas.
No.
Measure Name Desired Outcomes Required Service
| Performance Standard |
| Acceptable Quality Level (AQL) |
| Monitoring Method |
Incentives/Disincentives for Meeting or Not Meeting the Performance Standard
| 1 |
| Memorandum of Agreement (MOA) Regulatory Compliance |
Providers participating in the Medicare program, are required under federal law to have a Memorandum of Agreement (MOA) with a QIO. MOAs outline the QIO’s and provider’s responsibilities during the review process.
The BFCC-QIO must effectuate:
· Section 1866 (a)(1)(E) of the Social Security Act (The Act) requires providers of services to have an agreement with QIOs to release data related to patients when a QIO requests it.
· Section 1866 (a)(1)(F)(i) of the Act requires hospitals which provide inpatient hospital services paid under the Prospective Payment System (PPS) to maintain an agreement with QIOs to review the validity of diagnostic information provided by such hospitals, the completeness, adequacy and quality of care provided, the appropriateness of admissions and discharges, and the appropriateness of care provided for which additional payments are sought.
· Section 1866 (a)(1)(F)(ii) of the Act requires hospitals, critical access hospitals (CAHs), skilled nursing facilities (SNFs), hospices, LTACs, CORFs, and home health agencies (HHAs) to maintain an agreement with a QIO to perform certain functions.
| 95% compliance with execution of Memorandums of Agreement |
| 95% compliance with execution of Memorandums of Agreement |
| BFCC NCORC Performance Audit Criteria |
*Monitoring at month 12 and month 24
Numerator: Number of MOAs that meet regulatory requirements
Denominator:
A sample of 25 MOAs during the reporting period
Inclusion: All MOAs
Exclusion: none
· CPARS Performance Rating
| 2 |
| Physician Acknowledgement Statement Regulatory Compliance |
| Hospitals that are paid under the prospective payment system (PPS) have provided a signed acknowledgement from physicians who are being granted admitting privileges at the hospital. |
| The BFCC-QIO must monitor compliance with CMS regulation at 42 CFR 412.46 and ensure that each hospital has a physician acknowledgement statement on file for physicians billing for services provided in that hospital. |
| 95% compliance with execution of Physician Acknowledgement Statements |
| 95% compliance with execution of Physician Acknowledgement Statements |
| BFCC NCORC Performance Audit Criteria |
Numerator: Number of Physician Acknowledgement Statements that meet regulatory requirements
Denominator: A sample of 25 Physician Acknowledgement Statements during the reporting period
Inclusion: All Physician Acknowledgement Statements
Exclusion: none
· CPARS Performance Rating
· Visibility of Performance Audit Results
BFCC Aim 3
Generate a baseline measure for provider satisfaction with the BFCC-QIOs and establish an AIM for improvement, after the first year of contract period of performance.
Meas.
No.
| Measure Name |
| Desired Outcomes |
| Required |
Service
| Performance Standard |
| Acceptable Quality Level (AQL) |
| Evaluation |
Method Incentives/Disincentives for Meeting or Not Meeting the Performance Standard
| 3 |
| Provider Experience with Case Review Process |
| BFCC-QIO shall provide excellent customer service to provider callers. |
| The BFCC-QIO staff must be effective in the customer service domains of: |
· Communication
· Courtesy & Respect
· Accessibility & Responsiveness in the provision of case review services
90% Satisfaction Score on the Provider Experience Surveys of the BFCC-QIO Case Review Process
(80% - YR1 – YR2
90% - YR3 – YR5)
90% Satisfaction Score on the Provider Experience Surveys of the BFCC-QIO Case Review Process
(80% - YR1 – YR2
90% - YR3 – YR5)
Numerator:
Total number of completed provider caller surveys for case review services with a positive experience score
Denominator: Total number of completed provider caller surveys conducted for case review services
Data Source: BFCC-QIO Quarterly Provider Experience Survey performed by the BFCC Survey Center (BFCC-SC)
· CPARS Performance Rating
· Public Presentation of Results
· CMS Award (Certificate/Plaque)
BFCC Aim 4
Achieve 85% Medicare beneficiary satisfaction with BFCC-QIOs case review process over the contract period of performance.
Meas.
No.
| Measure Name |
| Desired |
Outcomes Required Service
| Performance Standard |
| Acceptable Quality Level (AQL) |
| Evaluation Method |
| Incentives/Disincentives for Meeting or Not Meeting the Performance Standard |
| 4 |
| Beneficiary Experience with Case Review Process |
| BFCC-QIO representative shall provide excellent customer service to Medicare beneficiary callers. |
The BFCC –QIO staff must be effective in the customer service domains of:
· Communication
· Courtesy & Respect
· Accessibility & Responsiveness in the provision of case review services
85% Satisfaction Score on the Beneficiary Experience Surveys of the BFCC-QIO Case Review Process.
(80% - YR1 – YR2
85% - YR3 – YR5)
85% Satisfaction Score on the Beneficiary Experience Surveys of the BFCC-QIO Case Review Process.
(80% - YR1 – YR2
85% - YR3 – YR5)
Numerator: Total number of completed beneficiary surveys for case review services with a positive experience score
Denominator: Total number of completed beneficiary surveys conducted for case review services
Inclusion: Contract Year Helpline Calls
Data Source: BFCC-QIO Quarterly Beneficiary Experience Survey Performed by the BFCC Survey Center (BFCC-SC)
· CPARS Performance Rating
· Public Presentation of All Results
· CMS Award (Certificate/plaque)
| 5 |
| Timeliness of Beneficiary Complaints and other Quality of Care (QoC) Reviews |
| Medicare Beneficiaries contacting the Beneficiary Helpline for a Complaint and other Quality of Care (QoC) Review will have the review completed within timeframes in the QIO Manual or task order. |
| The BFCC-QIO shall have Beneficiary complaints and Other Quality of Care (QoC) reviews completed within mandated timeframes. |
| 95% of beneficiaries with a completed QoC Review will have the review completed on time |
| 95% of beneficiaries with a completed QoC Review will have the review completed on time |
| Numerator: Total number of QoC reviews completed within mandated timeframes during the reporting period |
Denominator: Total number of eligible QoC reviews during the reporting period
Inclusion: Completed QoC reviews conducted based on beneficiary complaints, referred to QIOs and identified during other case review types
Exclusion: Technical Denials and any case/claim selected for BFCC NCORC review from a prior review period
Data Source: CMS Designated Case Review System - Quarterly Report
· CPARS Performance Rating
· CMS Award (Certificate/plaque)
| 6 |
| Timeliness of Immediate Advocacy Complaint Resolution |
| Medicare Beneficiaries contacting the Beneficiary Helpline shall be able to contact a BFCC-QIO representative who is able to effectively resolve oral complaints |
| The BFCC-QIO advocates on behalf of a beneficiary with providers using informal dispute resolution process to resolve an oral complaint a Medicare beneficiary has regarding the quality of Medicare covered health care received. |
90% of Beneficiaries receiving Immediate Advocacy will have their oral complaint resolved in 5 calendar days.
(5 days - YR1 – YR2 4 days - YR3 – YR5) 90% of Beneficiaries receiving Immediate Advocacy will have their oral complaint resolved in 5 calendar days.
(5 days - YR1 – YR2 4 days - YR3 – YR5) Numerator: Total number of IA cases completed within mandated timeframes during the reporting period
Denominator: Total number of IA cases during the reporting period
Data Source: CMS Designated Case Review System - Quarterly Report
· CPARS Performance Rating
· Public Presentation of Results
· CMS Award (Certificate/plaque)
| 7 |
| Timeliness of Appeals of Discharge/ Service Termination Reviews |
| Medicare Beneficiaries contacting the Beneficiary Helpline for a Discharge/ Service Termination Reviews will have the review completed within timeframes in the QIO Manual or task order. |
The BFCC-QIO shall have discharge/service termination reviews (BIPA, Grijalva and Weichardt reviews) completed within mandated timeframes.
| 95% of beneficiaries with a completed Discharge/ Service Termination Review will have the review completed on time |
| 95% of beneficiaries with a completed Discharge/ Service Termination Review will have the review completed on time |
| Numerator: Total number of Discharge/ Service Termination reviews completed within mandated timeframes during the reporting period |
Denominator: Total number of eligible Discharge/ Service Termination Reviews during the reporting period
Inclusion: Completed Discharge/ Service Termination Reviews (BIPA, Grijalva and Weichardt Reviews)
Exclusion: Any case/claim selected for BFCC NCORC review from a prior review period.
Data Source: CMS Designated Case Review System - Quarterly Report
· CPARS Performance Rating
· CMS Award (Certificate/plaque)
| 8 |
| Timeliness of EMTALA Reviews |
| EMTALA reviews will be completed within timeframes in the QIO Manual or task order. |
The BFCC-QIO shall complete EMTALA reviews within mandated timeframes and document these reviews in the CMS Designated Case Review System
| 95% of EMTALA reviews completed on time |
| 95% of EMTALA reviews completed on time |
| Numerator: |
Total number of EMTALA reviews completed within mandated timeframes during the reporting period
Denominator:
Total number of EMTALA reviews eligible for review during the reporting period
Inclusion: Completed EMTALA Reviews
Exclusions: Technical Denials
Data Source: Reports from CMS Designated Case Review System
· CPARS Performance Rating
| 9 |
| Quality of Care (QoC) Letter Compliance |
| BFCC-QIO QoC complaint review letters to Beneficiaries must be written in plain language and address all written complaints. |
| The BFCC-QIO shall meet all contractual requirements including those outlined in the QIO Manuals with reference to QoC complaint reviews. |
| 90% of Beneficiary QoC complaint review letters will meet contractual and QIO Manual requirements |
| 90% of Beneficiary QoC complaint review letters will meet contractual and QIO Manual requirements |
| BFCC-NCORC Performance Audit Criteria |
Numerator: NCORC sample of 10 cases per service area per quarter
Denominator: All completed cases per service area per quarter
No Exclusions
Data Source: CMS Designated Case Review System
· CPARS Performance Rating
BFCC Aim 7
Utilize state-based BFCC program data to identify trends and patterns to propose at least three improvements per year, for each contracted region over the contract period of performance.
Meas.
No.
| Measure Name |
| Desired |
Outcomes Required Service Performance Standard
| Acceptable Quality Level (AQL) |
| Monitoring Method |
| Incentives/Disincentives for Meeting or Not Meeting the Performance Standard |
| 10 |
| State-Based Innovations |
| State based innovation will give the BFCC-QIOs and their partners, the opportunity to address and target critical health care issues important to a particular community or state. |
| The BFCC-QIO will use state-based BFCC program data to identify trends and patterns to propose at least three improvements per year, for each contracted region. |
| Recommend at least three proposals per year that identify opportunities for local level innovations and improvements for each contracted region |
| Recommend at least three proposals per year that identify opportunities for local level innovations and improvements for each contracted region |
| Report to COR/SME |
| · CPARS Performance Rating |
· Monetary Incentive
· Public Awareness
· CMS Award
· CMS Quality Conference
BFCC Aim 8
Utilize QII data to identify trends and patterns to propose at least three improvements per year, for each contracted region over the contract period of performance.
Meas.
No.
| Measure Name |
| Desired |
Outcomes Required Service Performance Standard
| Acceptable Quality Level (AQL) |
| Monitoring Method |
| Incentives/Disincentives for Meeting or Not Meeting the Performance Standard |
| 11 |
| Quality Improvement Initiative (QIIs) |
| Quality Improvement Initiatives will give providers the needed technical assistance to effectively address quality issues |
| The BFCC-QIO will use QII data to identify trends and patterns to propose at least three improvements per year, for each contracted region |
| Recommend at least three proposals per year that identify opportunities for innovations and improvements for each contracted region |
| Recommend at least three proposals per year that identify opportunities for innovations and improvements for each contracted region |
| Report to COR/SME |
| · CPARS Performance Rating |
· Monetary Incentive
· Public Awareness
· CMS Award
BFCC Aim 9
Utilize BFCC program data and analytics to propose at least three focused reviews per year, for each contracted region, over the contract period of performance.
Meas.
No.
| Measure Name |
| Desired |
Outcomes Required Service Performance Standard
| Acceptable Quality Level (AQL) |
| Monitoring Method |
| Incentives/Disincentives for Meeting or Not Meeting the Performance Standard |
| 12 |
| Focused Review Initiative |
| BFCC-QIO refers to CMS opportunities for focused reviews to target areas of possible concern. |
| The BFCC-QIO will use focused reviews as follows: |
1. A review based on CMS-identified nationally recognized health care concerns.
2. A review based on poor performance on national reporting measures within the BFCC-QIO’s area.
3. A review in response to confirmed concerns where the concern could result in sanctions but where sanction activity has not yet occurred.
4. A review in response to a trend identified in case review data.
| Recommend at least three proposals per year for focused reviews that identify opportunities for innovations and improvements for each contracted region |
| Recommend at least three proposals per year for focused reviews that identify opportunities for innovations and improvements for each contracted region |
| Report to COR/SME |
| · CPARS Performance Rating |
· Public Awareness
· CMS Award
· Public Recognition
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