Definitions Related to Quality of Care Reviews

5020 – Definitions Related to Quality of Care Reviews (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Appointed Representative: An individual appointed by a beneficiary to represent the beneficiary in the Beneficiary Complaint Review process. See 42 CFR §476.1. Authorized Representative: An individual authorized, under State or other applicable law, to act on behalf of a beneficiary. The authorized representative will have all of the rights and responsibilities of a beneficiary throughout the processing of a Beneficiary Complaint. See 42 CFR §476.1. Beneficiary Complaint: A complaint by a beneficiary or a beneficiary’s representative alleging that the quality of services received by the beneficiary did not meet professionally recognized standards of care. A complaint may consist of one or more quality of care concerns. See 42 CFR §476.1. Beneficiary Complaint Review: A review conducted by a QIO in response to the receipt of a written beneficiary complaint to determine whether the quality of Medicare-covered services provided to the beneficiary was consistent with professionally recognized standards of health care. See 42 CFR §476.1. Beneficiary Representative: An individual identified as an authorized or appointed representative of a beneficiary. See 42 CFR §476.1. Corrective Action Plan: A written plan for correcting poor care that is gross and flagrant or is a substantial violation in a substantial number of cases. See §1156 of the Act, 42 CFR §1004.60, and CMS Publication 100-10, Quality Improvement Organization Manual, Chapter 9, Sanction and Abuse Issues. Criteria: Predetermined elements of health care, developed by health professionals relying on professional expertise, prior experience, and the professional literature, with which aspects of the quality, medical necessity, and appropriateness of a health care service may be compared. See 42 CFR §476.1. General Quality of Care Review: A review conducted by a QIO to determine whether the quality of Medicare-covered services provided to a Medicare beneficiary was consistent with professionally recognized standards of health care. A general quality of care review may be carried out as a result of a referral to the QIO or a QIO's identification of a potential concern during the course of another review activity or through the analysis of data. See 42 CFR §476.1. Gross and Flagrant Violation: A violation of an obligation resulting from inappropriate or unnecessary services, services that do not meet recognized professional standards of care, or services that are not supported by evidence of medical necessity or quality as required by the QIO. The violation must have occurred in one or more instances that present an imminent danger to the health, safety, or well-being of a program patient or place the program patient unnecessarily in high-risk situations. See 42 CFR §476.1. Health Care Service or Services: Services or items for which payment may be made (in whole or in part) under the Medicare or State health care programs. (QIOs review only those services for which payment may be made (in whole or in part) under Medicare.) See 42 CFR §1004.1(b). Immediate Advocacy: An informal alternative dispute resolution process used to quickly resolve an oral complaint a Medicare beneficiary or his/her representative has regarding the quality of Medicare-covered health care received. This process involves a QIO representative's direct contact with the practitioner and/or provider. See 42 CFR §476.1. Initial Determination Peer Reviewer: A practitioner reviewer who makes the interim and final initial determinations in the Quality of Care Review process. Medicare Health Plan(s): For purpose of this Chapter, a collective reference to Medicare Part C Health Plans, Medicare Part D Drug Plans, Cost Plans under section 1876 of the Act, and Health Care Prepayment Plans (HCPPs) under §1833 of the Act. Norm: A pattern of performance in the delivery of health care services that is typical for a specified group. See 42 CFR §476.1. Pattern of Care: Care under question has been demonstrated in more than three instances each of which involved different admissions. See 42 CFR §1004.1(b) Definitions. Peer Review: A review by health care practitioners of services ordered or furnished by other practitioners in the same professional field. See 42 CFR §476.1. Peer Reviewer: A reviewer who is either a physician or other practitioner who matches, as closely as possible, the variables of licensure, specialty, and practice setting of the physician or practitioner under review. The Initial Determination Peer Reviewer and Reconsideration Peer Reviewer must meet the requirements of this definition. See §1154(c) of the Act and 42 CFR §476.98(a) (1) and (b) for additional criteria. In cases in which there is no peer match available, the QIO may use another physician reviewer without the same expertise. See 42 CFR §476.98(a) (2). Physician: A doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatry, a doctor of optometry, or a chiropractor, as described in §1861(r) of the Act; an intern, resident, or Federal Government employee authorized under State or Federal law to practice as a doctor; and an individual licensed to practice as a doctor as described in this definition in any territory or commonwealth of the United States of America. See 42 CFR § 476.1. Practitioner: An individual credentialed within a recognized health care discipline and involved in providing the services of that discipline to patients. Provider: A health care facility, institution, or organization, including but not limited to a hospital, involved in the delivery of health care services for which payment may be made in whole or in part. See 42 CFR §476.1. Health care practitioners other than physicians: Refers to health professionals who do not hold a doctor of medicine or doctor of osteopathy degree but who meet all applicable State or Federal requirements for practice of their professions and are in active practice. See 42 CFR §§476.1 and 480.101(b). Quality of Care: The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. (Definition adopted from The Institute of Medicine). Quality of Care Concern: A concern that care provided did not meet a professionally recognized standard of health care. A general quality of care review or a beneficiary complaint review may cover a single or multiple concerns. See 42 CFR §476.1. Quality of Care Review: A review conducted by a QIO to determine whether the quality of Medicare-covered services provided to beneficiaries was consistent with professionally recognized standards of health care. A Quality of Care Review can be either a Beneficiary Complaint Review or a General Quality of Care Review. See 42 CFR § 476. Quality Improvement Initiative: Any formal activity plan designed to serve as a catalyst and support for quality improvement that uses proven methodologies to achieve these improvements. The improvements may relate to safety, health care, health, and value, and involve providers, practitioners, beneficiaries, and/or communities. Reconsideration: For written beneficiary complaints, reconsideration is the additional review performed by the QIO when requested by the beneficiary and/or the practitioner/provider when any of the parties is not pleased with the outcome of the QIO’s Final Determination. See 42 CFR §476.140(a). For General Quality of Care reviews, reconsideration is the additional review conducted by the QIO when requested by the provider and/or practitioner when he/she is not pleased with the outcome of the Initial Determination. See 42 CFR §476.170(a). Reconsideration Peer Reviewer: A Peer Reviewer who conducts the reconsideration segment of a Quality of Care Review. Significant Quality of Care Concern: A determination by a QIO that the quality of care provided to a Medicare beneficiary did not meet the standard of care and, while not a gross and flagrant or substantial violation of the standard, represents a noticeable departure from the standard that could reasonably be expected to have a negative impact on the health of a beneficiary. Standards: Professionally developed expressions of the range of acceptable variation from a norm or criterion. See 42 CFR §476.1. Substantial Violation in a Substantial Number of Cases: A pattern of providing care that is inappropriate, unnecessary, does not meet recognized professional standards of care, or is not supported by the necessary documentation of care as required by the QIO. See 42 CFR §1004.1(b), Definitions.