Sanction Committee Initial Review

9025.1 – Sanction Committee Initial Review (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) Only violations that the original peer reviewer determines meet the gross and flagrant/substantial violation or is a substantial violation in a substantial number of cases are sent to the Sanction Committee for sanction review. (See §9020.1.) The QIO must identify a violation and indicate whether the violation is a gross and flagrant violation or a substantial violation in a substantial number of cases. The referral should include at least the following information and documentation: • All physician reviewer Quality Review Determination (QRD) forms; • All medical information and documentation used in the review process; • All determination letter/correspondence with practitioners/providers; • Information received related to the offer of the Opportunity for Discussion Stage, if applicable; and • Any new evidence submitted in requesting the Reconsideration, if applicable. To properly identify a violation and determine whether a violation is gross and flagrant or a substantial violation in a substantial number of cases (the “reporting threshold”), the QIO should convene a Sanction Committee to receive and review all cases that have been initially identified as a violation meeting the reporting threshold. In addition to the initial review and identification of a violation that meets the reporting threshold that triggers referral for a sanction review, at least two additional physician reviewers with similar training as the practitioner or other person of concern should complete an additional review of the case(s), and complete a written summary of their review findings. These two additional case reviews should be completed within Five (5) business days and submitted to the QIO Sanction Committee. The Committee should make its initial finding within two (2) business days after these two additional reviews are completed. The Sanction Committee makes an initial finding based on all three reviews (i.e., the determinations of the original Physician Reviewer and two additional Peer Reviewers). This initial finding determines how 42 CFR §1004.40 is applied: • If the initial finding of the QIO Sanction Committee is that either (1) a violation did not occur or (2) the violation did not meet the reporting threshold, the QIO returns the case for continued processing of the case review that initiated the review of the QIO Sanction Committee. Case reviews are described in 42 CFR Part 476, and guidance on the case review process is provided in Chapter 5 of the QIO Manual. • If the QIO Sanction Committee finds that a violation that meets the reporting threshold occurred, the QIO proceeds with notification to the practitioner or other person. In addition, the QIO notifies the CMS COR of the initial finding and that the QIO is initiating action under 42 CFR §1004.40. NOTE: Any time the QIO makes an initial finding of a violation meeting the reporting threshold that involves a MHP as defined in Section 9010, the QIO must notify the COR and the respective Regional Office’s (RO) Division of Health Plans and Providers. The QIO must continue to notify the COR and the RO’s Division of Health Plans and Providers through each progressive step in the sanction review process and through the final QIO finding and report to OIG. Medicare Health Plans include Medicare Part C Plans (Medicare Health Plans), Medicare Part D Drug Plans, and cost plans under §1876 of the Act.