physician reviewer training: introduction & overview
DESCRIPTION
Physician Reviewer Training: Introduction & Overview. Sharon Hoffarth, MD, MPH, FACPM Chief Medical Officer. Objectives. Understand Physician Reviewer (PR) eligibility requirements Understand Primaris’ internal case review process - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/1.jpg)
Publication MO-13-05-CRThis 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 Training:Introduction & Overview
Sharon Hoffarth, MD, MPH, FACPM
Chief Medical Officer
![Page 2: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/2.jpg)
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
![Page 3: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/3.jpg)
• Respect of other physicians and providers
• Case review performed by physicians helps to
maintain physician autonomy
• Educational
• Prorated hourly reimbursement
Physician Reviewers – Benefits of being a PR
![Page 4: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/4.jpg)
Physician Reviewers -- Expectations
• Commitment to quality & excellence
• Knowledgeable about various settings of
care
• Flexible, willing to be called on short notice
![Page 5: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/5.jpg)
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
![Page 6: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/6.jpg)
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
![Page 7: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/7.jpg)
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
![Page 8: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/8.jpg)
How to contact Primaris – Electronic communication
• www.primaris.org
− e.g., [email protected]
• Email is NOT secure
− Do NOT use Primaris e-mail for case-specific
communication or for information with
patient, practitioner or provider identifiers
![Page 9: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/9.jpg)
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
![Page 10: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/10.jpg)
Publication MO-13-05-CRThis 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
Medicare Case Review Process
![Page 11: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/11.jpg)
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)
![Page 12: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/12.jpg)
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
![Page 13: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/13.jpg)
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
![Page 14: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/14.jpg)
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
![Page 15: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/15.jpg)
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
![Page 16: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/16.jpg)
• 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 process
![Page 17: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/17.jpg)
Case Review by Nurse
Refer?
CloseCase
QIO PRReview
Issue?
Send Letter toProvider/Physician
FinalLetter?
CloseCase
Send FinalLetter
Await Response(15-20 Days)
ResponseReceived?
CloseCase
Send FinalLetter
CloseCase
Send FinalLetter
CloseCase
QIO PR
Review
NOYES
YES NO
NO YES
NO YES
YESNO
Case ReviewProcess Algorithm
Physician &/or Provider Agree?
Close Case
![Page 18: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/18.jpg)
Case Review by Nurse
QIO PR Review
CloseCase
Refer?YES NO
Case Review Process Algorithm
![Page 19: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/19.jpg)
Case ReviewProcess Algorithm
QIO PR Review
Issue?
Send letter to Provider
CloseCase
YES
NO YES
![Page 20: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/20.jpg)
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?
![Page 21: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/21.jpg)
Case ReviewProcess Algorithm
FinalLetter?
CloseCase
Await Response (15-20 Days)
Send letter to Provider/Physician
YES
YESNO
![Page 22: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/22.jpg)
Case ReviewProcess Algorithm
ResponseReceived?
FinalLetter?
Physician & Hospital Agree?Send Final
Letter
CloseCase
Await Response (15-20 Days)
NO
NO YES
![Page 23: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/23.jpg)
Case ReviewProcess Algorithm
Physician &/orProvider Agree?
ResponseReceived?
QIO PR ReviewSend Final
Letter Send Final Letter
CloseCase
CloseCase
YES
YES NO
![Page 24: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/24.jpg)
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
![Page 25: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/25.jpg)
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
![Page 26: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/26.jpg)
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
![Page 27: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/27.jpg)
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
![Page 28: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/28.jpg)
Internal quality control
• Principles of utilization management
• Credentialing policies & procedures
• Conflict of interest
• Verification of peer status on case-by-case basis
![Page 29: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/29.jpg)
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
![Page 30: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/30.jpg)
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
![Page 31: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/31.jpg)
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?
![Page 32: Physician Reviewer Training: Introduction & Overview](https://reader035.vdocuments.mx/reader035/viewer/2022081520/5681489d550346895db5b1f9/html5/thumbnails/32.jpg)
For questions and additional information, call Rita Ketterlin at 1-800-735-6776, ext. 153