QIO Physician Review Process Description

9130.2 – QIO Physician Review Process Description (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) The QIO will conduct a 5-day review when the Regional Office DSC requests. The QIO physician peer reviewer will: 1. Provide his/her clinical assessment of the case based solely on the documentation the CMS Regional Office DSC provides; 2. Not state whether an EMTALA violation occurred; and 3. Complete the necessary paperwork, including: • EMTALA Physician Review Document Checklist (Appendix 9-11); and • EMTALA Physician Review Worksheet (Appendix 9-12). NOTE: It is NOT permissible for the QIO to offer a meeting to discuss the EMTALA review case with the hospital and/or practitioner(s). If the QIO physician reviewer needs additional information, the QIO is to communicate directly with the CMS Regional Office DSC that assigned the case. The QIO must forward the original EMTALA Physician Review Worksheet (Appendix 9- 12) provided by the Regional Office DSC to the QIO physician peer reviewer for completion. • The QIO can use the Physician Reviewer Worksheet provided by DSC as an original form to be completed by the Physician Reviewer. In addition, the QIO physician reviewer MUST include a legibly written (if not completed electronically) response and complete rationale for EACH question on the EMTALA Physician Review Worksheet. (See Appendix 9-12.) NOTE: CMS highly recommends that the QIO Physician Reviewer be well versed on key regulatory definitions, such as “emergency medical condition” and “stabilized” as well as the criteria for appropriate EMTALA medical screening examinations and transfers. (The QIO must provide all reviewers with the link to CMS’s interpretive guidelines explaining the EMTALA requirements in detail and encourage reviewers to consult this guidance when they have questions about any aspects of the Physician Review Worksheet. This guidance is available at: http://cms.hhs.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_v_emerg.pdf.) The QIO should enter the physician reviewer responses from the EMTALA Physician Review Worksheet (Appendix 9-12) verbatim into the CMS-designated review system if available, and keep a file copy for their records in accordance with record keeping requirements. • The QIO MUST NOT change the physician reviewer response unless the physician reviewer gives his/her approval. approval should be noted on the original EMTALA Physician Review Worksheet. • A copy of the original EMTALA Physician Review Worksheet (with the physician reviewer’s name redacted) should be forwarded to the CMS Regional Office DSC. NOTE: See the EMTALA Physician Review Document Checklist (Appendix 9-11) for a complete list of documents that the QIO physician peer reviewer reviewed. This checklist MUST be sent to the Regional Office DSC upon review completion. When completing the EMTALA Physician Review Worksheet (Appendix 9-12), the QIO physician reviewer should NOT provide a statement or opinion on either of the following: • His or her opinion as to whether an EMTALA violation occurred; and/or • Other observations about the case that are not specifically asked to be addressed (e.g., personal comments regarding the case). The criteria for an acceptable EMTALA physician review are as follows: 1. The review must meet all timeliness, administrative, and clinical requirements; and 2. The review must be consistent with: • Accepted standards of medical practice; • EMTALA statutory definitions; • Evidence-based clinical standards; and • Sound clinical judgment. If the CMS Regional Office DSC identifies an administrative concern with the EMTALA Physician Review Worksheet, the DSC will make a request to correct the issues. This may involve a direct discussion between the QIO and DSC Regional Office. NOTE: A concern with the EMTALA Physician Review Worksheet is considered administrative when the review is incomplete, unclear, internally inconsistent, and/or suggests an apparent lack of understanding of the EMTALA standards that govern the review. If the CMS Regional Office DSC identifies a concern with the clinical components of the review, then the DSC representative, CMS designated representative, and COR will discuss the case. As a result of this discussion, one or more of the following may occur: 1. The QIO COR will ask for a re-review by the same physician reviewer, or 2. The QIO COR will ask for a re-review (which would be the second re-review if the same physician who did the initial review has already conducted a re-review) by a completely new QIO physician reviewer. NOTE: A concern is considered clinical when the opinion rendered appears biased, does not follow accepted standards of medical practice, or addresses issues outside the expert competency of the QIO physician reviewer.