Beneficiary Complaint: Reconsideration Peer Reviewer

5060.1 – Beneficiary Complaint: Reconsideration Peer Reviewer (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) To fulfill the practitioner/provider and/or beneficiary’s right to reconsideration, and to provide all parties with an impartial and independent reconsideration of peer review, the Reconsideration Peer Reviewer should be different from the Peer Reviewer who conducted the Interim Initial and Final Initial Determinations. In making his/her determination, the Reconsideration Peer Reviewer shall review all information forwarded by the QIO. The Peer Reviewer shall use the QRD Form (Appendix 5-1.3) to render a determination(s). The Reconsideration Peer Reviewer receives the package from the QIO and initiates the reconsideration. In order to be an effective and fair review [See §476.130(b)(1)] provided upon request for a reconsideration, the Reconsideration Peer Reviewer must review each Quality of Care Concern identified in the complaint and any additional concerns identified by the QIO or the Initial Determination Peer Reviewer during the review of the medical information. The Reconsideration Peer Reviewer should also document the reconsideration review by completing the QRD Form for each concern. The process is as follows: 1. The Reconsideration Peer Reviewer evaluates the standard(s) that the QIO and the Initial Determination Peer Reviewer identified for each Quality of Care Concern on the QRD Form. 2. The Reconsideration Peer Reviewer checks off the appropriate box indicating whether he/she concurs or does not concur with the standard(s) of care for each Quality of Care Concern as delineated by the QIO and the Initial Determination Peer Reviewer. 3. If the Reconsideration Peer Reviewer determines that the standard(s) identified by the QIO staff member who prepared the case for review and/or Initial Determination Peer Reviewer for a specific concern(s) is incorrect or not appropriately thorough, he/she must identify the correct standard(s) and provide an explanation of the change. 4. For instances when the Reconsideration Peer Reviewer determines that the standard(s) is incorrect, he/she should include references to relevant literature/ research supporting his/her decision on the appropriate standard(s) of care and consult with the Medical Director to obtain the Medical Director’s concurrence on the standard to be used in evaluating the concern(s). NOTE: The QIO staff member who prepared the case for peer review should be included in this consultation with the Medical Director. Reconsideration Peer Reviewer Rationale/Justification Upon determining the standard(s) of care to be used, the Reconsideration Peer Reviewer then applies the standard(s) of care to the specific facts of the case and the quality of care concern(s) at issue. The Reconsideration Peer Reviewer evaluates the information contained in the medical information based on the standard(s) as identified, including each evidenced-based element of the standard(s) of care. CMS expects that each Reconsideration Peer Reviewer will: 1. Directly link his/her decisions to elements contained in the evidence-based standard(s), or in the absence of evidence-based standards of care, will use available norms, best practices, and established guidelines when deciding whether quality of care for each identified concern is met based on the facts of the case. 2. Assess the responsibility of the individual identified by the beneficiary if that individual is different from the individual who is responsible for the standard(s) that were not met. To conduct a complete and adequate reconsideration, CMS expects the Reconsideration Peer Reviewer to: 1. Consider any historical data pertinent to the concern(s) that the QIO provided. 2. Highlight specific evidence from the review of the medical information demonstrating that specific elements within the standard(s) of care that are or are not met. 3. Include any other information the Reconsideration Peer Reviewer deems relevant to his/her Reconsideration Determination. If the Reconsideration Peer Reviewer, in his/her determination, concludes that there are extenuating circumstances to take into consideration (e.g., emergent circumstances or exceptional complexity), the Rationale/Justification section of the QRD Form must contain an explanation of these circumstances including relevance, in order to be complete. After completing the Rationale/Justification portion for each concern on the QRD Form, the Reconsideration Peer Reviewer must identify (and document), by checking off the appropriate box, whether the standard(s) of care was met or not met for each concern. This decision/determination must be based on the analysis and justification. If the Reconsideration Peer Reviewer determines that the standard(s) of care was not met, he/she must also check off the appropriate quality of care determination box indicating whether: 1. The care grossly and flagrantly violated the practitioner/provider’s obligation to provide care that is of a quality that meets professionally recognized standard(s) of health care in one or more instances. 2. The care failed in a substantial number of cases (more than three) to substantially comply with the obligation to provide care that is of a quality that meets professionally recognized standard(s) of health care. 3. The care failed to substantially comply with the obligation to provide care that is of a quality that meets professionally recognized standard(s) of health care. 4. The care did not meet the standard of care, but was less than a substantial violation of the obligation to provide care that is of a quality that meets professionally recognized standard(s) of health care (i.e. It was either significant or non-significant). The QIO must ensure the Reconsideration Peer Reviewer completes his/her review of the medical information/package completely and accurately, adheres strictly to the requirements of the QRD Form to document the review thoroughly, and returns the review package to the QIO in the appropriate timeframe. The QIO may orally notify the beneficiary and practitioner/provider of its Final Decision within five (5) calendar days after the request for reconsideration or if later, five (5) days after receipt of any medical information needed to complete the reconsideration review. NOTE: If the QIO initially notifies the parties orally, it must follow up with a letter by 12:00 noon of the next calendar day. (See Appendix 5-5.1 and 5-5.2) The Reconsideration Peer Reviewer must sign and date the QRD Form and indicate the amount of time spent reviewing the concern(s). An electronic signature is acceptable when and if the feature is available through the CMS-designated or otherwise approved review system. NOTE: If the Reconsideration Peer Reviewer has identified one or more concern(s) as either gross or flagrant, or the care failed in a substantial number of cases (more than three) to substantially comply with the obligation to provide care that is of a quality that meets professionally recognized standards of health care as required by §1156(a) of the Act, the QIO must initiate sanction proceedings in accordance with Manual Chapter 9.