Medicaid Retrospective Review Process (Inpatient) #2010-07


TO: IPRO LIAISONS
FROM: Theodore O. Will, FACHE
Chief Executive Officer
DATE: December 6, 2010
RE: Medicaid Retrospective Review Process (Inpatient)
IPRO CONTACT:

Kathleen M. Fox, RN, MSA, Senior Director, Medicaid Review Operations, Extension 361 Wendy Ferguson,RN, Dip. Ed., Senior Director, AIMS Review Program, Extension 592

As there has been a considerable turnover of IPRO Liaisons at hospitals throughout New York State, this memorandum serves as education for new liaisons and as a restatement of the IPRO review retrospective process as it pertains to the review of inpatient hospital admissions billed under the NYS Medicaid Fee-for-Service Program.

IPRO currently has two (2) contracts with the New York State Department of Health (DOH) that include conducting retrospective review of Medicaid fee-for-service (FFS) beneficiary inpatient hospital stays to assess the necessity, appropriateness, and quality of the services that were rendered, as well as a validation of billing accuracy. These two contracts are (1) the NYS Medicaid Utilization Review and Quality Improvement Contract, which includes inpatient hospital review for the general Medicaid FFS population, and (2) the NYS AIDS Intervention Management System (AIMS) Contract, which includes review of inpatient and ambulatory care services for Medicaid beneficiaries with HIV/AIDS.

To facilitate the coordination of these and other IPRO program reviews, IPRO has worked with hospital representatives to establish a system of provider "liaisons" at each facility in the state. The facility liaison (also known as the IPRO Liaison) network includes over 200 facility contacts that are designated by each hospital's CEO to serve as the central point of contact between IPRO and individual hospital departments and clinicians. IPRO liaisons are an important link in the timely and efficient completion of the reviews, providing selected medical records, coordinating hospital schedules, maintaining awareness of IPRO's review activities, and handling review related correspondence and notifications. Our longstanding relationships with the IPRO Liaisons and their familiarity with both the review process and IPRO personnel have fostered mutual respect and cooperation that have contributed to the process efficiency.

The following document addresseslPRO's review policy as it pertains to NYS Medicaid Retrospective Review. Should you have any questions regarding information contained in this correspondence, regarding the review process in general, or pertaining to the Medicaid Review Program, please contact Kathleen M. Fox at (516)209-5361. For questions specifically pertaining to reviews conducted under the AIMS Program, please contact Wendy Ferguson at (516)209-5592.

A. IPRO Medicaid Retrospective Review Process

IPRO's retrospective review process for inpatient hospital admissions consists of a review of Medicaid beneficiary medical records and other clinical documentation to validate the quality of care, medical necessity, clinical coding, appropriateness of place of service, and length of stay associated with care. In addition, review includes validation that the claim was billed at the appropriate case payment rate. Also, the medical record is reviewed to assure that potential adverse events were appropriately reported to the NYSDOH NYPORTS database.

Each medical record requested for review must contain information that:

IPRO's retrospective review process begins as either an onsite or offsite review.

A.1 Onsite Review

Both the Medicaid Program and the AIMS Program conduct onsite retrospective reviews under each contract. Review volumes are based on the requirements as set by the specific DOH area responsible for the oversight of each contract. Even though both of these contracts are managed by IPRO, they function independent of each other, and are not limited by the requirements of the other contract. Therefore, both the Medicaid and AIMS review programs may schedule onsite reviews at a provider concurrently, at a volume set under each contract.

Under the Medicaid Review Program, IPRO currently limits onsite reviews to be scheduled no more than once every three weeks, with a review volume of approximately 250-275 cases per onsite review. In addition, providers with multiple campuses may be subject to this limit per campus. Under the AIMS Program, for both inpatient and ambulatory care claims are reviewed, therefore review volumes, processes, and timeframes may vary depending on the type of review being conducted. For questions regarding onsite review under the AIMS Program, please contact Wendy Ferguson, RN, Dip. Ed., Senior Director, at (516)209-5592.

IPRO's onsite review process begins with a notification letter to the hospital IPRO Liaison indicating that a review has been scheduled. The notification letter indicates the date(s) of the review, as well as the number of IPRO staff who will be conducting the review on each day. The notification letter includes a list of cases that must be pulled and ready for the non-physician (nurse) reviewers on the date of the review. The liaison will also receive a sealed package containing the files needed to conduct the review. This package is to be presented unopened to the IPRO reviewers upon arrival of the first day of review.

Upon arrival at the hospital, IPRO's staff (registered nurse (RN) reviewers) will request the pre-selected medical records reflected on the case list. The reviewer matches the case list to the medical records provided. If any record(s) are missing, the reviewer will request them from the liaison. When the onsite review is completed the reviewer compiles a list of record(s) that were identified as requiring further review (physician consultant or a coding supervisor) based upon the application of criteria or 3M DRG Grouper as well as the list of record(s) not provided during the review. The RN leaves this chart request list with the IPRO liaison at the conclusion of the onsite visit. Two copies of the chart request list are left at the hospital (one for their records and one to put on the copied charts to send to IPRO). The third copy is submitted to IPRO's Medical Records Department, informing them that the medical record(s) have been requested. Medical records received by IPRO must include a copy of the IPRO medical record request letter for identification purposes.

The hospital has 30 days to provide the medical record(s} requested on the chart request list.
Medical record(s) not received within 3D days will receive a technical denial (see Technical Denial section below for additional information).

A.2 Offsite Review

Both the Medicaid Program and the AIMS Program also conduct offsite retrospective reviews under each contract. Under the Medicaid Review Program, offsite chart requests are limited to two (2) requests per month, up to a total of 20 charts per request. These offsite chart requests are not inclusive of chart requests associated with missing records or referred cases from an onsite review. In addition, providers with multiple campuses may be subject to this limit for offsite chart requests per campus. Under the AIMS Program, for both inpatient and ambulatory care claims are reviewed, therefore review volumes, processes, and timeframes may vary depending on the type of review being conducted. For questions regarding offsite review under the AIMS Program, please contact Wendy Ferguson, RN, Dip. Ed., Senior Director, at (516)209-5592.

The IPRO Liaison will receive a notification letter and case list of records that must be copied and sent (with a copy of the request letter) to IPRO within 30 days of the date of the notification letter. Medical record(s) not received within the 3D-day timeframe will receive a technical denial (see Technical Denial section below for additional information).

A.3 Documentation Review

In order to conduct an accurate review, it is expected that the medical record will contain information to justify hospitalization, support the diagnoses and any treatments rendered, and describe the patient's progress and response to treatment.

A documentation error exists when information required for the RN to make a review decision is not available, e.g. the report of a diagnostic test, or the physician progress notes are missing from the medical record.

When a review determination cannot be made for a case because part of the medical record is illegible or missing, IPRO notifies the provider of the missinglincomplete documentation issue and gives the provider fifteen (15) calendar days from the date of the notice to produce the portion of the medical record in question.

If the requested documentation is not produced or is not legible, IPRO will issue a technical denial for the case (see Technical Denial section below for additional information).

Note: IPRO's documentation requests clearly indicate which parts of the charts were missing and are needed for the review. It is NOT necessary to copy the entire chart and send it in again.

A.4 Technical Denials

Technical denials are issued when there is a failure to provide requested information. Technical denials result in the recoupment of the funds paid for the claim. The hospital has one year from the date of the technical denial letter to provide the missing/incomplete documentation. Upon receipt of the missing documentation (within the specified timeframe), IPRO will process a reversal of the recoupment.

Technical denials are issued for the following reasons:

B. The Integrated Review Process (Inpatient)

IPRO's integrated review process for review of inpatient hospital admissions is a multi-level, multi- disciplinary process that includes an initial screening by a non-physician reviewer, using nationally- accepted, evidence-based criteria (see Medical Criteria section below), followed by up to three (3) levels of physician review. The flow diagram on the next page (Figure 1) highlights the various levels of the case review process.

B.1 Medical Criteria IPRO's review staff uses the following criteria to conduct Medicaid screening reviews:

B.2 Registered Nurse Review -Initial Screening

The initial review is conducted by a nurse reviewer (RN) using nationally accepted review criteria. If all aspects of care cannot be approved, the RN decides whether to refer the case to a physician consultant for medical review.

Case Review Not Approved - Potential Clinical Issue: If the RN has identified a potential utilization, quality, NYPORTS or coding/DRG concern that requires physician judgment, the case is referred to a physician consultant for further review.


Case Review Not Approved - Non-Medical Issue: In the following instances the RN can refer/deny the case without physician review:

The RN consults an IPRO Health Information Management (HIM) Validator for resolution of coding/DRG questions that do not require medical judgment. If resolved, the review is considered complete. For technical billing issues identified by the reviewer such as a wrong disposition code or a technical DRG issue, IPRO issues a preliminary denial without requiring a copy of the chart during an on-site review. The hospital is required to send a copy of the medical record if they disagree with the preliminary denial. Historically, technical coding issues have a higher rate of facility agreement, which saves the hospital time and the cost of copying the record.

Case Review Approved: If all aspects of care, as documented in the medical record, meet nationally accepted criteria, the RN completes the patient information worksheet and approves the case.

B.3 Review by Physician Consultant - Level 1 Review

IPRO's physician consultants (PC) are Board Certified and credentialed in compliance with URAC standards.

The physician consultant reviews the medical record to determine if the issue(s) identified by the RN, based on application of nationally-accepted and evidence-based criteria and/or their own clinical judgment, reflects a valid medical concern and if other valid issues not raised by the reviewer exist. For each concern, the PC summarizes the clinical information and provides a rationale supported by clinical information that substantiates the decision.

When the PC identifies a potential utilization, quality, DRG or NYPORTS concern, IPRO sends a preliminary inquiry to the IPRO Liaison for distribution to the appropriate parties. The inquiry explains the concerns raised and indicate the timeframe for responding. The liaison is encouraged to involve any other appropriate parties in addressing the concerns raised. For quality related findings, the PC also indicates the house staff, physicians, departments and/or services that may be a source of the concern and who should also receive a preliminary notice/inquiry.

IPRO understands and supports the need for provision of an opportunity for consultation and discussion regarding a peer review. Physicians, other health care practitioners, and providers are given an opportunity to discuss the case with a peer and to provide additional information regarding any potential denial determination or quality issues. This opportunity allows for physician-to-physician discussion or consideration of written information provided by the physician. During normal business hours PCs and/or the IPRO Medical Director are available specifically for these calls and facilities may request a phone appointment.

The hospital has 45 days from the date of the preliminary inquiry letter in which to respond. If appropriate, additional information that was not available at the first review (e.g., laboratory data) may be provided in support of the facility's position. If IPRO does not receive a facility response within the specified timeframe, a "no-response" final decision letter confirming the finding(s) is sent to the hospital. Once a "no-response" letter has been sent, the provider forfeits the second level review by a physician. The provider's only recourse is to request a reconsideration (appeal) review (see Review by Physician Consultant - Leve/3 Review).

8.4 Review by Physician Consultant - Level 2 Review

When IPRO receives a response from the facility within the appropriate timeframe, the PC assesses the provider response and determines if each potential finding has been resolved, modified, or confirmed. The physician documents the final determination and includes a rationale supported by clinical information for each finding.

IPRO issues a final determination notice to the hospital upholding or overturning the preliminary decision. The facility has 30 days to submit a request for a reconsideration (or appeal) review to the final denial of a quality, utilization, or DRG finding.

8.5 Review by Physician Consultant - Level 3 Review< (Reconsideration Review)

After consideration of IPRO's final determination(s), if the hospital wishes, it may file a request for a reconsideration (or appeal) review. This appeal request must be received by IPRO within 30 days from the date of the final determination letter. When submitting an appeal to a final determination, IPRO strongly encourages the submission of additional supporting information that was not originally submitted. If all relevant information has previously been submitted, please state in a cover letter that IPRO's determination has been reviewed and the facility is requesting the next level of appeal using the information already submitted. In either case, it is important for the hospital to articulate the rationale for continued disagreement with IPRO's finding(s).

To conduct the reconsideration (or appeal) review, IPRO selects a physician who has not had previous involvement with the case and is specialty-matched to the condition that is the subject of the reconsideration request. If the facility requests a certain specialty to review the case at the appeal level, a reasonable effort will be made to honor this request. IPRO provides the physician conducting the review with all prior review documentation, the additional information received with the request and the medical record for review.

During the reconsideration review, the physician assesses all information provided, addresses each category of finding previously confirmed, and determines if each finding is upheld (reconfirmed), overturned (resolved), or modified. IPRO notifies the facility as to the final decision on each reconsideration request, regardless of whether each finding is upheld (reconfirmed), overturned (resolved), or modified.

If the request for reconsideration is received after the 30-day timeframe, the final determination(s) is upheld, and IPRO will notify the facility that appeal review request is denied due to a late request for an appeal review.

For questions pertaining to the Medicaid Review Program, please contact Kathleen M. Fox, RN, MSA, Senior Director at (516)209-5361. For questions pertaining to the AIMS Program, please contact Wendy Ferguson, RN, Dip. Ed., Senior Director at (516)209-5592.

Page last modified: December 15, 2010
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