General Quality of Care Review: Reconsideration Peer Reviewer

5120.1 – General Quality of Care Review: Reconsideration Peer Reviewer (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) For CMS to treat the reconsideration as valid and fulfilling the right to reconsideration, the Reconsideration Peer Reviewer must be different then the Peer Reviewer who conducted the Initial Determination. In making his/her determination, the Reconsideration Peer Reviewer shall review all information forwarded by the QIO. The Reconsideration Peer Reviewer documents his/her review and determination using the QRD Form, for each Quality of Care Concern. The Reconsideration Peer Reviewer receives the package from the QIO and initiates the reconsideration. The Reconsideration Peer Reviewer must review each potential quality of care concern identified by the QIO and/or the Initial Determination Peer Reviewer. For each concern, the Reconsideration Peer Reviewer: • Evaluates the standard(s) the QIO and the Initial Determination Peer Reviewer identified on the QRD Form; • Checks off the appropriate box indicating whether he/she concurs or does not concur with the standard(s) of care as the QIO and Initial Determination Peer Reviewer delineated; • Determines if the standard(s) identified by the QIO and/or Initial Determination Peer Reviewer identified for a specific concern(s) is incorrect or not thorough, and, when appropriate, identifies the correct standard(s) and provides an explanation of the change; and • Includes references to relevant literature/research supporting the decision regarding the appropriate standard of care and consults with the Medical Director to obtain the Medical Director’s concurrence on the standard to be used in evaluating the concern(s) in instances where the standard of care has not been met. NOTE: The QIO staff member who prepared the case for the peer reviewer shall be included in this consultation. In the rare instance when a Reconsideration Peer Reviewer identifies a new concern, the Reviewer must notify the QIO for the QIO to initiate processing of the newly identified concern at the Quality of Care Review Stage. The Reconsideration Peer Reviewer must not evaluate the concern because the matter will be eligible for review by an Initial Determination Peer Reviewer. Completion of the Rationale/Justification Upon determining the appropriate standard of care, the Reconsideration Peer Reviewer then applies the standard of care to the specific facts of the case and the quality of care concern at issue. The Reconsideration Peer Reviewer evaluates the medical information based on the standard as identified, including each evidenced-based element of the standard of care. The Reconsideration Peer Reviewer must directly link his/her decisions to elements contained in the evidence-based standard), 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. The Reconsideration Peer Reviewer also assesses the individual responsibility for the standard(s) not met. In addition, the Reconsideration Peer Reviewer must consider any historical data pertinent to the concern(s) as provided by the QIO, highlight specific evidence from the review of the medical information demonstrating that specific elements within the standard of care are met or not met, and 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), he/she must thoroughly explain these justifications in completing the Rationale/Justification section of the QRD Form. The Reconsideration Peer Reviewer must complete a separate analysis for each quality concern. Upon completing the Rationale/Justification section, the Reconsideration Peer Reviewer must check off the appropriate box indicating his/her decision that the standard of care was met or not met. If the Reconsideration Peer Reviewer determines that the standard(s) of care was not met, he/she must also check off the appropriate box indicating whether: • The care grossly and flagrantly, in one or more instances, violated the practitioner/provider’s obligation to provide care that is of a quality that meets professionally recognized standards of health care. • 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 the professionally recognized standard(s) of health care. • The care failed to substantially comply with the obligation) to provide care that is of a quality that meets the professionally recognized standard(s) of health care. • 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 Reconsideration Peer Reviewer must complete his/her review of the medical information, adhere strictly to the format in the QRD Form, sign and date the form, and indicate the amount of time spent completing the review. The Reconsideration Peer Reviewer must return the package to the QIO with sufficient time to ensure the QIO is able to complete its review of the reconsideration. A QIO must notify the practitioner or the provider of the results within five (5) calendar days after the QIO received the request for reconsideration, or within five (5) calendar days after receiving any medical information or other records needed for the QIO to complete the reconsideration. NOTE: If the Reconsideration Peer Reviewer has identified a 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), then the QIO must initiate sanction proceedings in accordance with Manual Chapter 9.