Overview of the Review Process

The statutory basis for the review process may be found in Sections 1154, 1866(a)(1)(F) and 1886(f)(2) of the Social Security Act. The Act requires that a QIO review health care services furnished by physicians and other health care professionals, facilities and suppliers as specified in its contract with Centers for Medicare & Medicaid Services (CMS). TMF’s review of the medical record must determine (in accordance with the terms of its contract and 42 CFR Sec. 476.71):

Whether health care services are or were reasonable and medically necessary:
- For the diagnosis and treatment of illness or injury
- To improve functioning of a malformed body member
- For prevention of illness (e.g., pneumococcal vaccine)
- To provide hospice care for the palliation and management of terminal illness
Whether those health care services provided or proposed to be provided on an inpatient basis could, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient health care facility of a different type
Whether the quality of the health care services meets professionally recognized standards of health care. This includes, by requirement (Section 1154(a)(14) of the Act), review of all written complaints received from Medicare beneficiaries or their designated representatives alleging that the quality of services did/does not meet professionally recognized standards of health care
The validity of diagnostic and procedural information supplied by the hospital (DRG validation)
The completeness, adequacy and quality of hospital care provided to Medicare beneficiaries
The medical necessity, reasonableness and appropriateness of inpatient hospital admissions, discharges and invasive procedures
Whether a hospital has misrepresented admission or discharge information or has taken an action that results in the unnecessary admission of a Medicare beneficiary entitled to benefits under Part A

TMF employs a systematic approach to review and evaluation of the services provided to Medicare beneficiaries. Importantly, the objectives of the review are:

To identify quality concerns about care rendered to Medicare beneficiaries and to identify practice patterns associated with positive outcomes
To identify any systems of practice that may negatively impact care that is rendered
To determine the source(s) practitioners, facilities, etc. that are responsible for quality of care concerns
To determine if a significant departure from the expected standard of practice has occurred
To determine if a quality improvement plan is required to ensure appropriate care in future similar cases
To provide peer advice, including citations from the medical literature, as applicable, to help improve future care

As required by 42 CFR Ch. IV Sec. 476.100 and CMS contractual objectives, TMF must:

Utilize national or, where appropriate, regional norms when conducting review
Utilize criteria when assessing:
- The need for and appropriateness of an inpatient health care facility stay
- The necessity for surgery and other invasive diagnostic and therapeutic procedures
- The appropriateness of providing services at a particular health care facility or at a particular level of care

In its review process, TMF utilizes:

InterQual Level of Care and Evidenced-Based Criteria
Medical practice guidelines
Medical textbooks and literature
Other peer advice

TMF’s State Review Program Committee has the responsibility and authority to investigate and make findings concerning any potential quality of care concerns or alleged violations of the Statutory Obligations. This committee discharges these responsibilities through TMF staff, non-physician reviewers, physician reviewers, subcommittees and physician review panels.

Non-physician and physician reviewers carry out the review process. A physician reviewer must be:

A doctor of medicine, osteopathy, dentistry, podiatry or optometry, or another individual who is authorized under federal or state law to practice medicine, surgery, osteopathy, dentistry, podiatry or optometry (§1154(c) of the Act, 42 CFR 476.1, and 42 CFR 476.98(a))
Either be engaged in active practice in Texas or be military physicians who actively practice in a military or U.S. Department of Veterans Affairs health care facility in Texas
- Active practice means that the physician usually practices (on a routine basis) a minimum of 20 hours per week
- Active practice must also include active staff privileges in one or more Texas hospitals on a regular basis (42 CFR 476.98(a))