Other PRO Responsibilities

60.3 - Other PRO Responsibilities (Rev. 1, 09-11-02) A. Responsibilities Prior to Review The PROs are responsible for: • Specifying in their plan and instructions to practitioners and providers the type of evidence they require to document the care ordered or furnished to provide medically necessary, appropriate, and quality health care services; and • Applying professionally developed criteria for providing care, diagnosis, and treatment based upon typical patterns of practice within their geographic area to evaluate the medical necessity, quality, or appropriateness of services ordered or furnished. B. Ongoing Review Activities As a part of their ongoing review activities, PROs must: • Notify the appropriate agency of the State or Federal government when they become aware of situations which appear to be improper, but which do not fall within their review responsibilities (e.g., poor quality care in a renal dialysis center); • Use their authority or influence to enlist the support of other professional or Government agencies to ensure that all providers and practitioners for which they have review responsibilities comply with their obligations (see §1156 of the Act.); and • Perform beneficiary and physician outreach activities. C. Responsibilities as a Result of PRO Review To act upon information they obtain as a result of their review activities, PROs must: • Provide information on results of their review (e.g., annual report, periodic meetings with providers/practitioners); • Identify and seek correction of situations that, if continued, would result in violations under §1156 of the Act; • Submit reports to the Office of the Inspector General on providers and practitioners found to have substantially violated an obligation in a substantial number of cases, or to have grossly and flagrantly violated an obligation in one or more instances. This includes referring certain cases to State licensing boards. D. Additional Activities PROs perform all other activities specified in the Scope of Work, including any modifications, CMS regulations and instructions, and relevant statutory provisions. E. Payment Error Prevention Program (PEPP) In order to reduce inpatient PPS payment errors, PROs must initiate a program of Payment Error Prevention Projects (PEPPs). CMS defines the payment error rate as the number of dollars found to be paid in error out of the total of all dollars paid for inpatient PPS services. CMS provides State-specific error rates to PROs to evaluate performance.