Medicare Appeals and Review Processes

Performance Management and Process Improvement

• This is Chapter 3
• Authored by Mohamed Eldeeb
• Qualifications include CPHQ, CPHRM, LSSBB, TQM, SCRUM Master, TOT, and STEPPS master training.

Medical Record Review Process

• The process begins with determining what needs reviewing.
• The content depends on anticipated use
• Data is often screened using specific criteria.
• If the documentation meets criteria, no further review is needed.
• Reviewers often include physicians, nurses, clinical professionals, or data abstractors.
• Sampling is utilized due to time and resource constraints.
• The purpose is to reflect patient condition, timeframe for completion (usually never exceeds 30 days), sample size considerations (5% or 30), and the role of reviewers (non healthcare providers with detailed criteria).

Types of Clinical Review

• Prospective: Before treatment
• Concurrent: During hospitalisation (open MRD)
• Retrospective: After discharge (closed MRD)
• Revalidated: Peer review

Multilevel Review Process

• A multi-step process exists for review.
• Level 1: Screening and data collection by point of care professionals
• Level 2: Initial Analysis and confirmation of variation (peer review)
• Level 3: In-depth analysis (focus peer review)
• Level 4: Improve/design new processes
• Level 5: Monitoring and evaluation

Organization Measurements/Monitors

• The process is illustrated as a hierarchy
• Organizational reviews, clinical process reviews, operative & procedure reviews, medication management reviews, blood & blood component reviews, mortality reviews, and specific department reviews are all included
• These reviews are all part of the measurements and monitors of the organization.

Morbidity vs. Mortality

• Morbidity refers to illness or unhealthy states. It measures the frequency of a disease in a population.
• Mortality refers to death. It measures the death rate of a population.
• Both are used together frequently but represent distinct measures relevant for different purposes.
• Key data points include autopsy requests, organ donation requests, Do Not Resuscitate (DNR) status.
• Summary reports may include totals (all deaths, department-specific data), specialty, major diagnostic category, DRGs, and CMS mortality data summaries.

Seven Essential Intervention Categories for Patient Transition to Another Facility

• The categories listed in this slide include Medication management, Transition planning, Patient and family engagement and education, Information transfer, Follow-up care, Healthcare provider engagement, and Shared accountability across providers and organizations.

Physician Monitoring

• Medical staff departments regularly review quality management summary reports.
• Effectiveness of physician/LIP participation in organization-wide quality management/performance improvement is monitored.
• Evaluation can be integrated into annual organization-wide reviews.

Nursing Monitoring

• Nurse executives and other leaders participate in activities that affect patient safety and quality of care.
• A National Database of Nursing Quality Indicators (NDNQI) promotes standardization.
• Hospitals can compare their outcomes with other hospitals nationwide.

National Database of Nursing Quality Indicators (NDNQI)

• Includes various measures like nursing hours per patient day, patient falls, pain assessment, peripheral IV infiltration, pressure ulcer prevalence, and restraints.
• Data is reported in various formats including charts, summary reports, etc
• Data is presented using standardized scales, frequency measures, and benchmarks.

RN Information

• Education/certification, including specialized certifications for all full-time and part-time nurses, is outlined.
• Metrics tracked include: lactation consultant hours per 1000 live births, unassisted falls, patient volume (Emergency Department, perioperative services, ambulatory), device days, physical/sexual assault rates, care coordination, births data, nursing care minutes, and hospital readmissions data.

Patient Satisfaction Review

• Consumers assess quality based on access to practitioners, geographical access, service, relationship, and cost.
• Feedback assesses perceived quality, including complaints, positive perceptions, negative perceptions, and innovative ideas.

Patient/Member Feedback Mechanisms

• Mechanisms include surveys/questionnaires, telephone and face-to-face interviews, focus groups, internet email communications, complaint and grievance processes.

Patient/Member Satisfaction Surveys

• Designed to gauge patient satisfaction and identify issues. Critically important factors for planning and conducting these should be considered including survey length, language, layout, and type size.
• Regularly scheduled and/or periodic surveys may be used.

Patient Interviews

• Utilized to evaluate adherence to treatment plans, discharge plans, and determine health outcomes.
• Interviews can be conducted via phone, in person during office visits, hospital visits, or scheduled follow-up.

Focus Groups

• Small groups (6-10 individuals) with similar experiences, allowing structured discussion and gaining insights into topics/ideas.
• Key focus group rules include no right/wrong answers, one person speaking at a time, first-name basis, respect for others, and rules for cell phones.

Patient Complaints & Grievances

• Patients have the right to file complaints or grievances concerning healthcare or care quality.
• Complaints may be resolved quickly or may involve multiple levels of appeal.
• Hospitals and managed care plans must address grievances promptly and maintain records.

The complaint process:

• Patients are informed about how to file a grievance.
• Written complaints automatically become grievances.
• Postponed complaints or those needing further investigation also become grievances.
• Resolved complaints are documented.

Appeals:

• Appeals exist for disputes with organization decisions.
• Appeal procedures are used when dissatisfaction exists, rather than grievance procedures.
• A denial of authorization or payment for care at a certain level (e.g., hospitalization) requires an appeal request by the organization
• Organizations must clearly define the process used in written form.

Appeal and Grievance Differences

• An appeal is related to a denial or refusing to cover a particular treatment, service or medication.
• A grievance related to dissatisfaction of the patient from the plan representatives actions or behaviour.

Analysis Process

• Knowing what to do with the collected data. It must be systematically organized for decision-making processes.
• Data must be submitted promptly in an appropriate format to be effectively used for analyses.
• Collaborative involvement from those familiar with the processes is crucial for effective analysis.

Analysis Process: Questions

• What are the current levels of performance?
• Are patient/family expectations met?
• Are the care processes as expected?
• What is the stability of current processes?
• Are there areas open for significant analysis?
• Are there areas that can be improved?
• How effective was the performance improvement strategy?
• Are there design specifications for new processes met?
• Priorities need to be consistent with process priorities for improvements.

Importance of Analysis

• Data is needed to answer critical questions.
• Data is identified and defined.
• Performance data measured against benchmark values and standards.
• Self-comparison and comparison with other standards, guidelines, and regulations are part of the assessment process.

Self-comparison

• Data monitoring assists the organization in identifying trends and patterns over time relating to process improvements
• Comparison with prior data standards is vital
• Comparison with other organizations is also important

Initial Analysis

• The process to determine if the processes meet the expected parameters is outlined.
• Teams and/or committees with suitable responsibility are identified for initial analysis and interpretation of collected data
• Timeframes and intervals for data aggregation and analysis are detailed
• Consideration of volume of patient care, services, and procedures, and potential risk to patient care is essential

Third Step: Analysis

• Performance analysis must involve reviewing data accuracy, validity, and reliability.
• Determining any areas needing deeper analysis to address unusual variation in data.
• Individual cases (or sentinel events), potential issues, or improvement opportunities need identification.

Triggers For Intensive Analysis

• Sentinel events, unusual trends or patterns compared to expectations
• Significant variances in performance expectations for a process
• Serious adverse conditions could negatively affect outcomes.

Intensive Analysis

• Investigation steps are outlined for situations where variation is identified
• The process and responsibilities of those conducting this process analysis are outlined.
• Data analysis steps and their order are detailed in a flowchart

Analysis Process: Steps

• Step 1: Data collection for prioritized performance measures.
• Step 2: Ongoing systematic aggregation and initial analysis.
• Step 3: Statistical tools/techniques to measure acceptable process variability
• Step 4: Monitoring unacceptable levels of variation to identify needed changes.
• Step 5: External comparative data/guidelines
• Step 6: Identifying, initiating changes

Dissemination of Performance Improvement Information

• The analysis results need dissemination within the organization and to external users.
• Effective communication of information for decision-making is vital to ensure that responsibility to maintain and improve patient care is achieved.
• QM/PI reports are routinely shared with governing bodies or quality management committees and leaders
• The results should be presented in a timely manner.

Analysis Process: Outcomes or Reporting

• Analysis may reveal opportunities to improve systems, knowledge, and individual behavior
• Key performance indicators, specific performance issues, and outcomes of QI projects.
• Reporting requirements are dependent on governing body structure, and state/federal guidelines.
• Regular reporting is essential.

Suggested Communication Methods for Reports

• Reports of data aggregation should use tools like charts and tables.
• Data analysis feedback to teams, committees, departments, staff, and leaders is essential.
• Performance and indicator information and data needs to be reported regularly.

Minutes Addressing Performance Improvement

• Project statement/charter
• Project summaries/reports
• Project reports/progress
• Project summary reports and "storyboards"
• Findings
• Conclusions
• Recommendations
• Actions
• Follow-up

Performance Measure (Quality Indicator) Data and Information for the Governing Board

• This table provides a comprehensive list of key performance measures (quality indicators) that are often reported. Included are those relating to key quality projects and specific process-related issues.

• Key performance measures/quality indicators are listed showing status of strategic quality initiatives, significant patient care issues, root cause analysis and various performance measure examples.

• Overall, the presented study notes details aspects of performance monitoring, process improvement, medical record review data collection, analysis, reporting, patient satisfaction and related metrics in healthcare.