QIO 8th Scope of Work Polly Warner, Chief Review Officer UR Workshops, November 2005 - PowerPoint PPT Presentation


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QIO 8th Scope of Work Polly Warner, Chief Review Officer UR Workshops, November 2005


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Title: QIO 8th Scope of Work Polly Warner, Chief Review Officer UR Workshops, November 2005

QIO 8th Scope of WorkPolly Warner, Chief Review
OfficerUR Workshops, November 2005
  • The enclosed material was prepared and assembled
    by Northeast Health Care Quality Foundation
    (NHCQF), the Medicare Quality Improvement
    Organization (QIO) for Maine, New Hampshire and
    Vermont, under contract with the Centers for
    Medicare Medicaid Services (CMS), an agency of
    the U.S. Department of Health and Human Services.
    The contents presented do not necessarily
    reflect CMS policy.

QIO 8th Scope of Work
  • Contract period 8/1/05-7/31/08
  • Quality Improvement Tasks
  • Nursing homes
  • Home health agencies
  • Physician offices
  • Part D Benefit
  • Hospitals
  • Beneficiary Protection Tasks

Nursing Homes
  • Improve clinical performance
  • High risk pressure ulcers
  • Physical restraints
  • Depression symptoms
  • Pain
  • Promote person directed care and organizational
    culture change to improve resident and staff
    satisfaction and decrease CNA/LNA turnover

Home Health Agencies
  • Reduce acute care hospitalizations
  • Improve performance on OASIS measures (bathing,
    transferring, management of oral medications,
    pain, ambulation/locomotion, dyspnea, urinary
    incontinence, status of surgical wounds)
  • Increase assessment and use of immunizations
  • Promote use of telehealth technologies

Physician Practices
  • Improve effective management of chronic diseases
  • Diabetes
  • Heart disease
  • Improve reliability of delivery of preventive
  • Cancer screening (mammography)
  • Adult immunizations
  • Promote use of electronic clinical information to
    improve clinical performance (DOQ-IT)

Part D Benefit
  • Work with physicians, pharmacists and
    Prescription Drug Plans to develop quality
    improvement projects to improve safety in the
    delivery of prescription drugs

  • Improve clinical performance
  • Improve the Appropriate Care Measure (ACM)
    results for AMI, HF and pneumonia
  • Promote adoption of standard processes of care
    for the Surgical Care Improvement Project (SCIP)
  • Surgical site infection, cardiovascular
    complications, venous thromboembolism, ventilator
    associated pneumonia, promote use of fistulas for

  • Hospital Reporting and Validation
  • Improve validity, timeliness and completeness of
    Annual Payment Update (APU) measure submission
  • Encourage submission of full Hospital Quality
    Alliance (HQA) measure set

  • Evaluate the use of Computerized Physician Order
    Entry (CPOE)
  • Assess and improve patient safety climate

Beneficiary Protection
  • Beneficiary Complaint Response Program
  • Beneficiary Appeals
  • Other Case Reviews
  • Quality Improvement Plans
  • Hospital Payment Monitoring Program (HPMP)

Beneficiary Complaint Response Program
  • Promote beneficiary satisfaction with the
    complaint process and outcomes
  • Many settings with Medicare covered services
  • Flexibility to use case review, mediation or
    other alternative dispute resolution options to
    handle complaints

Expedited Beneficiary Appeals
  • Appeals of notices of noncoverage issued in the
    hospital inpatient setting
  • Appeals of notices of noncoverage issued in other
  • SNFs, including SNF swing beds
  • HHAs
  • Hospices
  • CORFs

Other Reviews
  • Retrospective notice of noncoverage review
    (general acute care hospitals only, cases with
    patient liability only)
  • Hospital requested higher weighted DRG review
  • EMTALA review
  • Referrals from CMS, FI, OIG, etc.

Quality Improvement Plans
  • QIPs may relate to quality concerns, billing
    errors, coding issues, admission decisions,
    issuance of notices of noncoverage the whole
    spectrum of QIO review

  • Measure, monitor and reduce incidence of improper
    FFS inpatient payments
  • Monthly random sample reviewed to estimate
    national and state payment error rates

PEPPER Changes 3rd Quarter Fiscal Year 2005
  • Utilization target areas
  • New target area
  • 3 day SNF qualifying stays
  • Deleted target areas
  • One day stay transfers
  • Same day readmissions
  • Revised target area
  • DRGs 239/243/253 now just DRG 243, Medical Back

PEPPER Changes (cont.)
  • Coding target areas
  • New target areas
  • Complication/comorbidity pairs
  • DRG 089 Simple Pneumonia
  • Deleted target area
  • DRG 475 Respiratory Diagnosis with Ventilator

PEPPER (cont.)
  • National PEPPER training Web based
  • Maine
  • November 10, 2005 1200-100 pm
  • New Hampshire and Vermont
  • November 15, 2005 1200-100 pm
  • Contact www.pepperinfo.org for additional
    information, registration, recorded sessions

Other Resources
  • Top 20 DRG Report
  • Data reports on request
  • Updated Compliance Manual
  • Web Site
  • www.nhcqf.org - Review Services
  • Helpline
  • 1-800-772-0151 ext 165 (Review Services)
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