QIO Update May 3, 2013

1. QIO Update May 3, 2013 Rhonda Finstad Director, Case Review

2. Overview • Healthcare Compliance – What it means • to Mountain Pacific • Revisions to QIO Program Regulations • Resources

3. Healthcare Compliance What it means to Mountain Pacific • Mountain-Pacific is committed to the highest standards of legal and ethical conduct. • Our continued success and strong public image is dependent upon the responsible and ethical conduct of its staff, board of directors, vendors and contractors, and services performed or delegated

4. STANDARD OF CONDUCT • Organization of four affiliated quality improvement organizations within the states of Montana, Wyoming, Hawaii and Alaska. • All four organizations are subject to Mountain-Pacific’s Corporate Compliance Program • The Compliance Program applies to all entities and individuals, whether employed by Mountain-Pacific or any other subsidiary, agents and independent contractors who perform services under any of Mountain-Pacific’s contracts whether as a prime contractor or subcontractor.

5. Key essentials of our Compliance Program • Corporate Compliance Handbook – available on our intranet site • Compliance Training – new employee orientation and annual training • Compliance Hotline • Audits – conducted annually • Investigations – as needed • Background Checks – for every new employee, contractor and consultant • Compliance Officer • Corporate Compliance Committee • Reports to the Board of Directors, Compliance Committee and the Chief Executive Officer

6. Revisions to the QIO Program Regulations

7. Quality of Care • Beneficiary Complaints • Immediate Advocacy (oral) • Beneficiary Complaint Review (written) • General Quality of Care Review • Referrals from other CMS entities (MACs, RACs, OIG, etc.) • Quality concerns identified during other reviews (appeals, HWDRGs, etc.)

8. Definition of Immediate Advocacy • §471.1 • Informal ADR process used to quickly resolve oral complaints • Direct contact with the provider and/or practitioner • Usually within (8) hours but no more than 2 business days. • Look back 6 months • Discontinue IA if serious issues come to light

9. Definition of Beneficiary Complaint Review • §471.1 • Written • Whether the quality of Medicare covered services provided to the beneficiary was consistent with professionally recognized standards of health care • 3 year “look back” • Anchor point: date on which care giving rise to complaint occurred • Electronically submitted complaints = “written.” • Complainant does not wish to remain anonymous

10. Changes Not Implemented Yet • QIO Request for Medical Information • Due within 14 calendar days of request • Sooner if our preliminary determination is complaint involves a potential gross and flagrant or substantial quality of care concern • Must tell provider/practitioner about the complaint and request a contact name for the opportunity for discussion • 14 calendar day time frame for requests related to other review types, e.g., medical necessity reviews, HWDRGs

11. Opportunity for Discussion • Notify by telephone of Interim Initial Determination and offer to discuss • Hold discussion no later than 7 calendar days from initial offer • Written statement must be received within 7 calendar days of initial offer • More time in rare circumstances • No additional evidence may be submitted

12. Reconsideration Requests • Complaints filed after July 31, 2014! • Beneficiaries as well as providers and practitioners • Request can be made by telephone or in writing no later than 3 calendar days following initial notification • Parties must be available to answer questions • Right to provide more information

13. Confidential Information that Explicitly or Implicitly Identifies Patients • §480.101(b) Confidential information includes any information that explicitly or implicitly identifies an individual patient • New regulations at §480.145 to allow beneficiaries to authorize the use of their confidential information • “patient-centeredness” aim of the QIOs’ current scope of work requires more patient involvement • Goal of many patient and family engagement efforts is to incorporate a “real-world person’s” experiences to demonstrate the compelling and urgent need for healthcare delivery reform • Beneficiaries have asked to participate in meaningful ways

14. Authorization Form • §480.145(a) Authorization Form is required in order to use or disclose a beneficiary’s confidential information • Use must be consistent with authorization

15. Content of Authorization Form • 480.145(b) • A description of the information • Name or other specific identification of the QIO(s) and QIO point(s) of contact • Name or other specific identification of the person(s), or class of persons, to whom the QIO(s) may disclose the information or allow the requested use • A description of each purpose of the requested use or disclosure -- “at the request of the individual” • An expiration date or an expiration event -- “end of the QIO research study” “none” . . .or similar language • Signature of the individual and date

16. Secure Transmission of Electronic Versions of Medical Information • PROPOSED CHANGES: • §476.78(b)(2)(iii) QIOs’ right to exchange secure transmissions of electronic versions of medical information, subject to the QIO’s ability to support the exchange • Secure electronic faxes • Reduce costs for providers and practitioners because they would no longer have to print and mail paper copies

17. Jimmo vs. Sebelius • Settlement in the Medicare Improvement Standard case, Jimmo v. Sebelius, approved on January 24, 2013 • Clarifies existing CMS policy - Not an Expansion of Medicare Coverage • The Settlement Agreement does not modify, contract, or expand the existing eligibility requirements for receiving Medicare coverage. • Clarifies when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration • Coverage cannot be denied based on the absence of potential for improvement or restoration.

18. Jimmo vs. Sebelius continued • CMS Plans to conduct the following activities: • Clarifying Policy – Updating Program Manuals • Educational Campaign – Informing Stakeholders • Claims Review • CMS will complete the manual revisions and educational campaign by January 23, 2014, which is within one year of the approval date of the settlement agreement.

19. CMS Fact Sheet • A fact sheet on the Jimmo v. Sebelius Settlement Agreement has been published to CMS’ website. It can be accessed through the following link: • http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo -FactSheet.pdf

20. MAC Updates

21. MAC Updates • Quality of Care Referrals to QIOs • Effective 9/25/12 • MACs/FIs /Carriers will only refer Quality of Health Care Concerns to QIOs • Instructed to turn off all automated edits/processes generating QIO referral prior to a complex medical review of the claim •  Identification of quality referrals during complex medical review

22. MAC Updates – continued • Concerns identified as not meeting professionally recognized standards of health care • Example: medically unnecessary procedure • Referred to QIO after payment determination and/or claim adjustment • Mountain-Pacific updated our Joint Operating Agreements (JOAs) with our MACs

23. Resources

24. RESOURCES • MLN - Medicare Claim Review Program Booklet • Describes contractor types and their responsibilities • http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MCRP_Booklet.pdf

25. Resources – continued • PEPPER Reports • PEPPER can support a hospital or facility’s compliance efforts by identifying outliers for risk areas. • This data can help identify both potential overpayments as well as potential underpayments. • http://www.pepperresources.org/

26. Office of Inspector General Links • Receive Email Updates https://oig.hhs.gov/ • Compliance 101 and Provider Education https://oig.hhs.gov/compliance/101/index.asp • Compliance Guidance https://oig.hhs.gov/compliance/compliance-guidance/index.asp • Special Fraud Alerts, Bulletins, and Other Guidance https://oig.hhs.gov/compliance/alerts/index.asp • Advisory Opinions https://oig.hhs.gov/compliance/advisory-opinions/index.asp • Audits Conducted by the OIG https://oig.hhs.gov/reports-and-publications/oas/cms.asp

27. Questions? Contact Information: Rhonda Finstad, RHIA, CCS Director, Case Review 1-800-497-8232 ext. 5892 rfinstad@mtqio.sdps.org This information is brought to you by Mountain-Pacific Quality Health, the Medicare Quality Improvement Organization for Montana, Wyoming, Hawaii and Alaska, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Contents presented do not necessarily reflect CMS policy. 10thSOW-MPQHF-HI-13-53.