Beneficiary Complaint: Preparing the Quality Review Decision (QRD)

5050.2 – Beneficiary Complaint: Preparing the Quality Review Decision (QRD) Form (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Once a determination is made about the number of complaints and the specific Quality of Care Concern(s) to be addressed during the review, a Quality Review Decision (QRD) Form must be prepared for each complaint (See Appendix 5-1.3, “Quality Review Decision (QRD) Form”). The QRD Form is the only form authorized for documenting the concerns addressed in a Beneficiary Complaint Review. CMS created the QRD Form to better account for the multiple individuals involved in reviewing a beneficiary complaint and to ensure information related to every beneficiary complaint—and in particular, every quality of care concern—is maintained in an organized, detailed, and consistent fashion throughout the review process. Using the CMS-designated case review system, the QIO: 1. Prepares a QRD Form that sets out each individual concern; and 2. Forwards the package to the Initial Determination Peer Reviewer as soon as possible following receipt of the medical information. In addition, the QIO completes the following steps for each concern: 1. Evaluates the beneficiary complaint and each Quality of Care Concern in accordance with §5030.1, Scope of Complaint. 2. Evaluates the quality of care with regard to the admission diagnosis and treatment plan established for the beneficiary, if applicable. 3. Evaluates the quality of care for any blatant issues (e.g. Never Events identified as hospital acquired conditions that could have been reasonably prevented through the application of evidence-based guidelines) (See National Coverage Determination (NCD) made as part of CR 6405). 4. Researches evidence-based practices related to each Quality of Care Concern(s) while considering the definition of Quality Care, including reference to relevant norms and criteria. If no quality of care standard(s) exists, then the QIO will use available norms, best practices, and established guidelines and recommend a potential quality of care standard(s). In completing this step, the QIO must thoroughly research all available information, including the following: • Nurse screening criteria (e.g., InterQual, Milliman); and • Generally available resources, including information available via Internet searches. 5. Complete an assessment section for EACH Quality of Care Concern in the complaint and/or identified. 6. Evaluate additional information pertinent to the case, but unrelated to the standard(s) of care. This may include: • CMS-available information, including Web-based resources (e.g., Nursing Home and Hospital Compare); and • State-based resources, including Web-based literature/information as well as practitioner-specific information related to license revocations and referrals to the State medical conduct organizations. 7. Research all available data, at a minimum of three (3) years from the date of service, to determine whether the QIO has received similar complaints on the same practitioner and/or provider and/or if other potential concerns related to the same practitioner/provider are identifiable. 8. Prepare the package for forwarding to the Initial Determination Peer Reviewer.