Administrative Memos

199905

FROM: Theodore O. Will, Chief Executive Officer
DATE: Jun 07, 1999
SUBJECT: Medcaid Review Determination Profiles - Dec 1, 1998 - Feb 28, 1999
IPRO CONTACTS:

Joshua Muscat, Assistant Director, Data Operations/Analysis, ext. 530

Enclosed are three (3) reports that describe the findings for Medicaid utilization, DRG, and quality reviews conducted by IPRO during the second quarter review period ending February, 1999 under the Medicaid Case Payment System. The first report summarizes the review findings for your hospital in statistical format. The second report is a new report which summarizes the review findings for all hospitals in your peer group. The third report includes case specific review determination results for your hospital.

The following guide provides an explanation of each of the four (4) categories of review findings listed on the Summary Review Determination Reports:

The retrospective review category includes cases which may have been randomly selected or selected for specific utilization criteria including: readmission within thirty-one (31) days, hospital stays less than the DRG lowtrim, transfers, etc. This category also includes the results of quality of care reviews, performed for a sample of cases with in-hospital mortality and/or complication codes, as identified from

the paid claims data.

The DRG review category includes cases selected specifically for DRG validation. DRG validation is also performed routinely for cases selected as part of a utilization review.
The enhanced UR Program review includes the review of admissions to psychiatric exempt units in acute care facilities, and DRG review for cases in which the length of stay is the minimum allowable length of stay for billing a full DRG.
The other review category includes cases awaiting alternative level of care (ALC) placement for more than two (2) days on a prepayment basis; cost outlier review, discharge review (IPRA); auto denials (category not in use during this time period) and preadmission review.

The following definitions are provided for each column heading included on the Summary Review Determination Report:

Universe of cases is the number of Medicaid patients discharged and billed by the hospital during this time period as per the adjudicated claims tape provided by MMIS.
The cases selected are cases selected for IPRO review. Not all of the cases that are selected are reviewed in the current quarter. Some selected cases may be reviewed in a subsequent quarter.
Cases completed include all case reviews completed during the reported quarter and may include cases selected for review from a previous quarter.
Cases approved are the number of cases with no utilization, DRG or quality concerns identified after review has been completed.
Percent of cases approved is the quotient of cases approved divided by the number of cases selected.
Cases denied are the number of cases with either a confirmed utilization, DRG, or quality concern. These concerns reflect the final decision made during the review quarter.
Percent of cases denied is the quotient of cases denied divided by the number of cases selected.
There are five types of denials. These include admission, continued stay, DRG, quality, and technical denials. A technical denial is issued when all or parts of the medical record are unavailable for review. The sum of these denials may not equal the total number of case denials. This is because some cases may receive more than one (1) type of denial, e.g., quality and DRG.

The Case Listings Report is a list of cases with reviews completed during the report period. The case listing includes the patient's name, the IPRO batch number and review decisions (for admission, LOS, and DRG) or an indication if the case was technically denied. If an appeal was made for a denial, the results of a successful appeal would not be reflected in the case listing.

Case listings are generated only for the first three review categories (i.e., Retrospective, DRG and Enhanced UR Program). In addition, please note that if a technical denial was issued, there are no results indicated for the review categories.

Should you have any questions or comments about these reports or the reporting of review findings, please feel free to contact Joshua Muscat, Assistant Director, Data Operations/Analysis, at extension 530. We appreciate your input.