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July 31, 2014
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Detailed Description of the Review Process

The TMF medical record review process includes opportunities for the involved party(ies) to submit information that may not be apparent from the documentation in the medical record. The involved party(ies) may be requested to provide a rationale for the care provided, explain why the services met professionally recognized standards of health care and submit supporting documentation. This process is outlined below.

Preliminary Review

The preliminary review process includes three phases:

Phase I
Upon receipt of the medical record, the non-physician reviewer (NPR) performs a review to ensure the necessary components of the record appear to be present. The NPR formulates a case summary and questions to address any potential issues associated with the medical record documentation or beneficiary complaint concern(s).

Phase II
The medical record is reviewed by a physician reviewer (PR). This review includes addressing the quality of care and/or utilization questions (medical necessity of services and/or admission and DRG changes) asked by the NPR. The PR identifies any potential quality of care concerns based on his or her findings in the medical record. These concerns may be based on the NPR questions or may be based on information in the medical record. The PR provides the rationale for each potential or resolved concern. One of two determination categories is identified for each concern:

  • “No substantial improvement opportunities are identified.”
    When this determination is made, the case is closed with or without issuing recommendations for improving care to the involved practitioner, facility and/or other health care professional.
  • “Care could have been better.”
    When this determination is made, one of the following must be assigned for each potential concern:
    • “Care was grossly and flagrantly unacceptable.”
    • “Care failed to meet generally accepted guidelines or usual practice.”
    • “Care could reasonably have been expected to be better.”
    The PR returns this documentation to TMF. The PR must complete his or her review within a specific timeframe.

Phase III
The NPR finalizes the TMF Notice of Potential Quality Issue letter. The letter is issued to the practitioner, facility and/or other health care professional. It offers an opportunity for all involved parties to respond to the inquiry and provides clarifying information including:

  • A summary of the case
  • The potential concerns
  • The time limit for reply
  • The recommendation that the involved parties coordinate a joint response, if appropriate
Final Review

The final medical record review process begins at the end of the 20-day period allowed for response to the preliminary inquiry, even if there has been no response from the involved parties. This part of the review process includes two phases:

Phase I
The PR reviews the response(s) to the TMF Notice of Potential Quality Issue letter, if any. If a response(s) is received, the PR formulates a decision based on the review of the response information from the involved party(ies) and review of the medical record. If no response(s) is received, the review determination is based on the preliminary medical record review and becomes the final review decision.

Following the final decision, the PR determines recommended action(s). There are five possible actions that may be recommended. Dependent upon the review decision, the PR may recommend one or more of the following actions:

  • No recommendations are made
    When no recommendations are made, no additional action needs to be taken.
  • Advising that the provider/practitioner consider an alternative approach to future care
    Recommendations that a provider/practitioner consider an alternate approach to care are made when the PR wants to communicate to a practitioner about guidelines or usual practice or suggest advice regarding best practices.
  • Requiring a quality improvement plan
    Quality improvement plans 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.
  • Initiation of intensified review activity
    Intensified review activity is the review of a selected group of medical records that may identify a pattern of care similar to the record(s) with confirmed quality of care concerns. This review may begin for the provider/practitioner when care failed generally accepted guidelines or usual practice that may indicate to the PR that the identified failure could have happened again in similar cases/situations.
  • Immediate referral to licensing authority and initiation of sanction activity
    Immediate reporting to the licensing authority and initiation of sanction activity should occur when care is grossly and flagrantly unacceptable (section 1156 of the Act) and/or where there is immediate danger to the health and safety of other beneficiaries (section 1160(b) of the Act).

Phase II
The NPR completes and sends the TMF Notice of Final Quality Issue and/or Final Procedure and/or Admission Denial letter(s) to the practitioner, facility and/or other health care professional. This letter offers an opportunity for all involved parties to request a rereview of the final decision and the option of submitting additional information. It also includes:

  • The final quality of care concern(s)
  • The PR’s decision rationale
  • The source of the quality of care concern(s)
  • The time limit for requesting rereview of quality of care concern(s)
  • Reconsideration of any procedure and/or admission denial

When rereview of a quality concern and/or reconsideration of an admission and/or procedure denial is requested, a PR who was not involved in the previous review of the medical record and is of a like medical specialty performs the rereview. The matched specialty PR makes the decision to confirm or resolve the indentified concerns based on the medical record documentation and any additional information. This review is carried out in the same manner as Phase I of the final review process (above).

Panel Review

When the PR review process for quality of care concerns is completed and quality of care concerns remain, further review is performed by a TMF physician panel consisting of two State Review Program Committee (SRPC) members functioning as the Quality Improvement Activities Subcommittee (QIASC). These physicians are responsible for oversight of all review decisions and recommendations. They are also responsible for making a final determination regarding quality improvement activities to be initiated for each case or group of cases. The subcommittee’s decision is communicated to the involved party(ies) via a Quality Improvement Activity Letter.

The QIASC will consider the medical record documentation, additional information and rationale(s) previously provided by the PR(s) during final review or rereview. The QIASC may recommend that the SRPC carry out the PR’s recommended quality improvement activity or modify it to include one or more of the actions listed under Phase I of the final review process (above) and/or:

  • Invitation to an informal meeting (in person or via conference call)
    For all patterns of quality of care concerns (except gross and flagrant situations, for which the sanction process applies), regardless of the source of the concern, the involved party(ies) may be given an opportunity to discuss the pattern of concerns. The avenue of discussion is an informal meeting during which the involved party(ies) is given the opportunity to present their views on the care rendered and to answer questions posed by a panel of physicians appointed by the SRPC. Panel members are chosen based on similar areas of expertise and familiarity with settings. The panel comes to a decision regarding further action based on the discussion and presentation of additional documentation.
  • Invitation to a formal meeting (in person)
    When care has been determined to be grossly and flagrantly unacceptable or a practitioner has demonstrated a pattern of care that does not meet professionally recognized standards of health care in a substantial number of cases, a formal meeting will be requested. In the formal meetings, the physician is strongly encouraged to bring additional information to respond to the determination and to use the meeting as an opportunity to present his or her views of the care rendered. TMF is required to use a process for the formal meeting that is mandated by CMS. This process governs the language used in correspondence and the makeup of the physician panel. The process also requires that a final decision be made to recommend whether the practitioner should be referred to the Office of Inspector General (OIG) for sanction or placed on a corrective action plan. The practitioner may have an attorney and/or physician counsel present and may have expert witnesses present to testify on their behalf. TMF takes a verbatim record of the meeting (via court reporter) which will be provided to the practitioner upon completion, if requested.

The SRPC will notify the Texas Medical Board (TMB) if it determines that a physician has demonstrated a pattern of care that does not meet professionally recognized standards of health care. Notification will occur when at least one of the following conditions has been met:

  • The physician has one or more confirmed quality of care concerns that places the Medicare beneficiary in an avoidable high-risk situation and there is concern regarding protection of either Medicare beneficiaries or other patient populations
  • The physician:
    • Continues to have confirmed quality of care concerns following implementation of a corrective action plan
    • Is non-compliant with a corrective action plan and attempts to elicit his or her cooperation have failed
    • Has failed to successfully complete a corrective action plan
  • The physician has one or more confirmed quality of care concerns and, at a meeting with a panel of TMF physicians, the physician by his or her responses to questions from the panel, demonstrated a lack of medical knowledge that could place beneficiaries and/or other patient populations at risk for adverse effects.
  • The physician has a substantial number of cases with confirmed quality of care concerns and elects not to admit Medicare patients to a setting in which his or her care can be monitored by TMF.

TMF will also notify the TMB when:

  • A sanction recommendation is made to the OIG
  • TMF determines that there has been a gross and flagrant violation or a substantial violation in a substantial number of cases and has recommended a corrective action plan the physician has failed to successfully complete
  • A physician poses a continuing threat to the public welfare through the practice of medicine, as determined by the SRPC

Throughout the TMF medical record review process the involved party(ies) is provided with opportunities to respond to inquiries and give input prior to and after the final case decision. TMF’s decisions are goal-directed to enhance patient care through the support of practitioners and facilities and utilization of quality improvement activities.

TMF has received Independent Review Organization accreditation from URAC. TMF is a GSA Advantage Contract Holder.