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  • Empire State Medical, Scientific and Educational Foundation, Inc.* Empire State Medical Scientific and Educational Foundation, Inc.DISPUTE RESOLUTION REVIEW PROGRAM

    Health Care Financial Management AssociationApril 14, 2011

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*About Us Not for profit corporation focusing on quality medical peer reviewIndependent Medical Review Organization sponsored by the Medical Society of the State of NYRegistered Utilization Review Agent with the NYS Bureau of Managed CarePursuing certification with URAC, NCQA27 years experience in medical peer review

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Relevant ExperienceProvide Dispute Resolution Review services throughout New York StateProvide External Appeal Review services for the State of Connecticut Serve as Medicaid Peer Review Agent through subcontract with IPROPerform coding/compliance review for physician offices throughout NYS

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Dispute Resolution ProgramInternal Review Process Providers and Payors contractually agree to an internal dispute resolution/appeal process External Review ProcessProviders and Payors contractually agree to an external dispute resolution/appeal processContract should designate an outside entity to serve as the dispute resolution/external appeal agent

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Dispute Resolution Program (cont.)Items your Contract should address:Internal Review/Appeal ProcessSpecify the timeframe for initiating the appeal processSpecify the number of reviews available (initial and final versus final review only)Specify the steps for initiating each step of the processSpecify the issues that may be appealed

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Dispute Resolution Program (cont.)Items your Contract should address (cont.):External Dispute Resolution Review ProcessDesignate the Entity to be used for external dispute resolution reviewIdentify who will initiate the review process (ie hospital or payor or either)Specify the timeframes for initiating the dispute resolution review processIdentify the issues that may be disputed

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Dispute Resolution Program (cont.)Items your Contract should address (cont.):External Dispute Resolution Review Process (cont.)Specify if one or two reviews are available through the external process Designate the final responsibility for the review feeContractually agree that both parties will be bound by the decision of the external agent

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Dispute Resolution Program (cont.)Issues ReviewedCorrect coding and/or DRG assignmentMedical necessity of admission and/or length of stay (Acute and/or Exempt Unit)Level of careAcute/Observation/Skilled/AlternateInpatient versus outpatient level of careOther issues as requested

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Dispute Resolution Program (cont.)Review Criteria UtilizedInterqual Adult and Pediatric Level of Care criteriaMilliman Care Guidelines NYS Rules and RegulationsUHDDS Coding Guidelines3M/HIS NYS Grouper/PricerAMA 1995/1997 CPT Coding Guidelines

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Dispute Resolution Review ProcessMaterials received from requesting partyDispute Resolution ApplicationCopy of the Medical RecordSupporting documentation for issue in disputeNotification of Review Request is sent to other party with instructions to submit comments

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Dispute Resolution Review Process (cont)Case is reviewed by nurse and/or coderNurse reviews medical necessity issuesCoder reviews DRG/coding issuesCase is referred to physician specialistReview results are published

    Empire State Medical, Scientific and Educational Foundation, Inc.*

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Important to RememberDocumentation is Key!!!State clearly the issue in questionState clearly your position and supporting argumentCite any applicable medical criteria or coding guidelines referenced for your reviewAlways respond to a denialDocumentation is Key!!

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Case #1Case submitted by hospital because payor disagrees with secondary diagnosis dehydration (276.51).Hospital Argument:Briefly, this case involves a 70 year old male admitted emergently with nausea, vomiting, weakness and passing out on the day of admit. The admission diagnosis on the ER record was weakness and dehydration. The MD ordered IV fluids for treatment of the dehydration. These were continued through day #4 of the hospital stay.

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Case #1 (cont.)Hospital Argument (cont.)The dehydration was an additional diagnosis that affected this episode of care. It meets the criteria for a secondary diagnosis as it was clinically evaluated, required treatment and increased nursing care. Thediagnosis of hypovolemia is included in the discharge summary as a final diagnosis.Parts of Record Referenced by Hospital: Discharge summaryAdmission physician orderEmergency room record

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Case #1 (cont.)Payor Argument:We continue to maintain that this patient was not dehydrated. This 70 year old man with adrenal insufficiency presented with weakness and episodes of falling with inability to get up. His BUN/Creatinine was 7/0.9 which is not consistent with dehydration, but rather than hypokalemia which we agree the patient had. Dehydration is deleted.Parts of the Record Referenced:None specifically referenced

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Case #1 (cont.)ESMSEF Decision:Per our physician specialist, the principal reason for this patients symptoms and admission is adrenal crisis from acute renal insufficiency. Weakness, hypotension and dehydration are medical consequences. He also had hypokalemia during this admission. Dehydration is a valid diagnosis and was evaluated and treated during this hospital stay.

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Case #2Case submitted by hospital because payor denied continued stay from 10/6-10/10 as not medically necessary. Patient was in hospital from 9/24-10/10.Hospital Argument:Patient was a 38 year old male with a history of AIDS who was admitted with pneumocystitis pneumonia. He was treated with IV antibiotics and slowly improved. His blood glucose levels remained elevated due to high doses of steroid therapy. On 10/6, patient felt well, was out of bed and had no shortness of breath noted. He was being instructed on Insulin administration and medication teaching. Visiting nurse was being arranged. Patient was discharged 10/10.

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Case #2 (cont.)ESMSEF Decision:Per our physician specialist, the continued stay after 10/6 is not substantiated. The patient was afebrile and denied shortness of breath. The O2 sat was greater than 90% consistently on room air and blood sugars were improving. Insulin administration was begun early in the admission and could have been continued on an outpatient basis since patient had in-home nursing care services. The continued stay was not substantiated.

    Empire State Medical, Scientific and Educational Foundation, Inc.

  • Empire State Medical, Scientific and Educational Foundation, Inc.*Case #3Case submitted by hospital because payor disagrees with principal diagnosis diverticulitis (562.10) and secondary diagnosis COPD (496).Hospital Argument:This was a 70 year old female admitted with abdominal pain and diagnosed with diverticulitis. The patients history was significant for COPD. This was a complicating diagnosis that was present on admission and affected this episode of care. It was documented by the physician in the H&P, progress notes and on the face sheet. The COPD was clinically evaluated, treated with Combivent inhaler and required nursing monitoring. It was correctly assigned for this episode of care.

    Empire State Medical, Scientific and Educational Foundation, I

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