Chapter 4 TOPS_Amend 2_05122011.docx

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S3-02-01 Baltimore, Maryland 21244-1850

Office of Clinical Standards and Quality

TOPS MEMORANDUM

QIP TOPS

CONTROL NBR: 2011-01

DATE: May 12, 2011

SUBJECT: Revision of Chapter 4 of the QIO Manual, “Case Review” – Amendment #2 as of May 12, 2011

The purpose of this memorandum is to highlight changes to processes detailed in Chapter 4 of the QIO Manual, “Case Review.” All changes outlined in this memorandum are effective as of August 1, 2011.

CMS has restructured and redesigned the QIO case review process to achieve maximum value. A strong emphasis has been placed on improving efficiencies. Therefore, CMS is implementing a centralized intake process for all QIO case reviews. The National Coordinating Center for Beneficiary and Family Centered Care (NCCBFCC) will serve as the national intake unit for the following QIO case review types: beneficiary-initiated Quality of Care Reviews, referred and QIO-initiated Quality of Care Reviews, Emergency Medical Treatment and Labor Act (EMTALA) Reviews, reviews of provider and health plan discharge/service termination decisions, reviews of hospital admission denials, and Higher-Weighted DRG Reviews.

While the NCCBFCC may be the first point of contact in many case, as always, Beneficiaries may enter the process from different referral points including the QIO itself. As unconditional teamwork and boudarilessness is an expectation for both the QIO and the NCCBFCC, it is expected that both entities will work together to ensure a satisfactory experience for the beneficiary and that the case is handled in the most appropriate manner.

The revised Chapter 4 of the QIO Manual will be separated into sections that encompass functions of the NCCBFCC: intake, triage, referral, Immediate Advocacy (IA), Re-Review of Quality of Care Reviews, and Data Analysis, and Internal Monitoring. A QIO training related to Chapter 4 of the QIO Manual will be held in the future to review the changes noted in this memorandum. More information about the QIO training, including the date, time, and registration information will be forthcoming.

In addition, the triage unit will provide excellent customer service, resolving quality of care concerns that do not require a medical record review, and referring beneficiaries to appropriate entities to meet their needs.

During the intake stage, the NCCBFCC’s Review Analyst (RA) will be responsible for collecting basic information (either orally or through a written statement) about the beneficiary and information regarding the review request. If specific information is not readily available, the NCCBCC must ensure appropriate follow up is made to obtain the information from the beneficiary or the beneficiary’s representative.

The NCCBFCC will process the intake stage in the Case Review Management Information System (CRMIS) for all Quality of Care Reviews along with Benefits Improvement and Protection Act (BIPA), Grijalva, Weichardt, Hospital-Requested, Preadmission HINN, and Admission HINN Reviews. Each QIO will enter into a subcontract with the NCCBCC that specifies the handoff point between the NCCBFCC and the QIO for each review type. For example, some QIOs may delegate to the NCCBFCC the responsibility for obtaining medical records and/or for validating provider notices.

Additionally, for Quality of Care Reviews, the RA will be tasked with making a preliminary determination regarding whether the potential quality of care concern is eligible for immediate advocacy during the intake stage.

Quality of Care Reviews: Triage, Referral, Immediate Advocacy, and Re-Reviews

During the triage stage of a Quality of Care Review, the NCCBFCC RA will utilize information gathered during the intake stage to prioritize and classify the potential quality of care concern, and, as appropriate, to initiate an initial investigation. The NCCBFCC will resolve potential quality of care concerns that do not require referrals or medical record reviews, and classify potential quality of care concerns utilizing the Picker Institute Principles of Patient-Centered Care.

In addition, each potential quality of care concern will also be prioritized into one of four levels to ensure that the acuity of the concern is used as a driver for a timely response.

· Level I: High Priority. Allegations ranging from serious harm to death of a beneficiary.

· Level II: Moderate Priority: Allegations of an adverse event to the beneficiary, or that the care provided does not meet professionally recognized standards.

· Level III: Low Priority: Allegations of a minor threat to beneficiary that does not require medical record review.

· Level IV: Allegations that do not fall within the scope of the QIO Program. No action required by the NCCBFCC and/or the QIO.

The referral stage of a Quality of Care Review ensures that the appropriate entity handles the investigation and resolution of the quality of care concern.

Level I and Level II cases will be referred to the appropriate State Survey Agency and QIO; Level III cases will be referred to the appropriate entity or handled at the NCCBFCC; and Level IV cases will be tracked and trended for data purposes only.

The NCCBFCC will use Immediate Advocacy (IA) to reach a resolution in Level III cases arising from a beneficiary/representative complaint. During IA, the RA will assist the beneficiary/ representative with resolution of their quality of care complaint through immediate action or intervention. Depending on the nature of the complaint and the decision of the beneficiary/representative, the RA may use a conference call/three-way call or make a call on behalf of the beneficiary/representative as methods to resolve the beneficiary’s quality of care concern. After the IA has been carried out, the NCCBFCC will send a letter to the beneficiary/representative summarizing the actions taken to resolve the complaint.

The beneficiary/ representative, practitioner, or provider will also have the ability to request a Re-Review of a Quality of Care Review. Upon receipt of a Re-Review request, the NCCBFCC RA will request the required information to conduct a re-review and notify the local QIO of a reconsideration request. Re-Review documents will include but will not be limited to the following:

· Physician Reviewer Assessment Form (PRAF)

· Medical record(s)

· Copies of letters to beneficiaries/representatives

· Information received during the Opportunity for Discussion Stage

The NCCBFCC will provide Data to CMS in order for CMS to undertake state, regional and national level monitoring. CMS will conduct monitoring of QIO performance to ensure the QIO is meeting the needs of beneficiaries and operating efficiently and effectively.

Inter-Rater Reliability (IRR) reviews are an important aspect of monitoring. The NCCBFCC will initiate, perform, and document IRR analyses to assist CMS to perform any necessary follow-up in case of unsatisfactory IRR review findings for a QIO.

IRR reviews will be conducted regularly by the NCCBFCC and if issues arise, IRR reviews may also be performed on an ad hoc basis.

If you have questions regarding this TOPS Memo, please contact Linda D. Smith by e-mail at Linda.Smith@cms.hhs.gov or by telephone at 410-786-5650.

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