Administrative Memos

200301

FROM: Theodore O. Will, Chief Executive Officer
DATE: Feb 25, 2003
SUBJECT: 7th Scope of Work Quality of Care Review Process
IPRO CONTACTS:

Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment, Extension 364

The purpose of this memorandum is to make you aware of the Medicare 7th Scope of Work (SOW) beneficiary protection (Task 3) quality of care review process. The current review process has been expanded by the Centers for Medicare/Medicaid Services (CMS) to include the Quality Improvement Organization's (QIO's) recommendation(s) for concern specific action. This expanded process places greater emphasis on a systematic approach to evaluating quality issues.

As in previous SOWs, the review process is initiated by the nurse reviewer. Quality of care concerns are referred to a peer physician reviewer (PC). After his/her review, the PC makes an initial determination about the essential issues within the case. Involved practitioners/providers are offered an opportunity for response before a second level review and final determination are rendered. When quality concerns are confirmed, an opportunity for re-review within 30 days of the final quality concern notice is also afforded. Under the 7th SOW, The Centers for Medicare and Medicaid Services (CMS) has added a " recommendation for action" determination to the PC quality of care review process. This requires that when quality of care concerns are identified, physician reviewers will also recommend one or more of the following possible actions be taken to address the concern(s) identified:

  1. Advising that the provider/ practitioner consider an alternative approach to future care

    2. Recommendations that a provider/practitioner consider an alternate approach to care would be made to communicate to a practitioner about guidelines, usual practice, or suggest advice regarding best practices.
    This plan of action is appropriate when the care provided could be enhanced through use of newer techniques, or adoption of new processes. Often in this situation, PCs may cite the medical literature, or references to new guidelines, or sources for standards of care that are different than the care provided by the physician or provider.

  2. Requiring a Quality Improvement Plan

    3. Quality Improvement Plans (QIPs) are indicated when there is potential for better care to result from improvement in the system(s) or process of care delivery and/ or practitioner participation in an education program or change in practice.
    QIPs are practical in situations where care could be improved through:
    • Enhancing systems for the delivery of care
    • Educational programs for practitioners
    • Opportunities to otherwise improve care
    Once a QIP plan is created and accepted by all parties, QIOs will monitor the progress of the plan's implementation and will follow up with providers to determine whether improvement has occurred. If no improvement is observed, QIOs will determine the action(s) that must be taken next with respect to the provider/ practitioner to address/ resolve the situation.

  3. Initiation of intensified review activity

    4. Intensified review activity may be suggested for the provider/practitioner when care failed generally accepted guidelines or usual practice that may indicate that the identified failure could have happened again in similar cases/situations. This finding may also involve requiring a Quality Improvement Plan (QIP)-see above.

  4. Referral to licensing authority and initiation of sanction activity

    5. Reporting to the licensing authority and initiation of sanction activity is recommended when care is (1) grossly and flagrantly unacceptable (section 1156 of the Social Security Act (the Act)) and/ or (2) where there is immediate danger to the health and safety of other beneficiaries which are not appropriately addressed through improvement activities (changes in process or education) (section 1160(b) of the Act).

Please note, IPRO's internal quality control processes require that recommendations for quality improvement plans, intensified review and referral to licensing authorities are reviewed by IPRO's Medical Director. Sanction recommendations may only be made by IPRO's Board of Directors.

Should you have any questions in regard to this memorandum, please feel free to contact Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment at extension 364.

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