November 16, 2010
Patti G. Weinberg, RPA, MPS
Medicaid/State Healthcare Assessment
1979 Marcus Avenue
Lake Success, New York 11042
IPRO, as a new review component of the Medicaid UR/QI contract, has been instructed by the New York State Department of Health (NYSDOH) to conduct a retrospective review of home-based services provided to an individual by Certified Home Health Agencies (CHHA) for more than 120 days.
The NYSDOH has identified a sample of Medicaid patients to be included in this review for which IPRO has been requested to conduct a qualitative review of their medical records. Ongoing sampling and reviews will continue throughout IPRO’s contract cycle. As part of the reviews, information will be abstracted from the medical records supplied by the CHHA to assess medical necessity of services, appropriateness of established treatment plans, timely certifications and possible alternative services. Pattern analyses on agency deficiencies will be provided to the NYSDOH subsequent to the review.
In an effort to accommodate agency workload, IPRO will perform onsite reviews to eliminate the need for photocopying these large patient records. As contractually required, facilities will be notified two weeks prior to the onsite visit. Additionally, within 24-48 hours of the review, IPRO will provide a case list of medical records for which reviews are required. These records will need to be available in a single location and in their entirety for the IPRO review to occur (e.g., signed physician orders for services must be present on all records, plans of care for each certification period, OASIS and other documentation to support services provided and more will be reviewed during our onsite visit and should be provided in the patient record). It is understood that in some instances, an agency will have more than one location; therefore patient records will exist in more than one location. In these instances, IPRO will accept medical record photocopies from these alternate locations with submission of these copies to IPRO for offsite review. Agencies may also transport their records to a single location of their choosing for IPRO review. We understand agency staffing and resource limitations and will accommodate these alternate arrangements as often as is feasible.
The attached document provides detail on the review process. Should you have any questions about the contract or the review process, please contact Diane Thorp, MHA, BSN, RN, RAC-CT: Assistant Director at (516) 326-7767, Extension 325.
Patti G. Weinberg
CHHA Review Process
As part of IPRO’s contract with the New York State Department of Health, IPRO conducts retrospective Medicaid beneficiary medical record reviews for Certified Home Health Agency (CHHA) services to assess the necessity, appropriateness, duration, and quality of the services that were rendered, as well as, a validation of billing accuracy. The review will initially focus on services provided in 2009.
The Retrospective Review Process begins with a 24 to 48 hour advance notification of onsite review to the agencies as described in the review process which follows.
IPRO Medicaid CHHA Retrospective Review Process
IPRO’s retrospective review process consists of a qualitative review of Medicaid beneficiary medical records and other clinical documentation to validate the medical necessity of services, appropriateness of established treatment plans and types of services, timely certifications, potential for alternative services, and includes a review of the quality of care for provided services.
Each medical record requested for review must contain the necessary documents for billing Medicaid for patient care. Note that this is a qualitative review in which agency response to review decisions will not be considered. Therefore it is critical that agencies provide all documentation during the onsite review. For example, signed and dated plan(s) of care which specify the services ordered including documentation to support the need for those services; recertification documentation noting changes in patient condition and/or needs for less or greater services, and the like, are areas under review. Information that justifies the billed services will be evaluated during the review with failures in documentation and justification reported to the NYSDOH on an individual and aggregate basis. Currently, the project is looking for patterns of potentially inappropriate billing, missing documentation supporting said billing and/or a need for lesser levels of care or settings. As such, this project will not be accepting information after the review date. Please be sure to include all documentation within each record at the time of review. Records not provided for review will be considered failures to provide supporting documentation for ANY services for the patient in question and will be reported as such to the NYSDOH.
IPRO’s CHHA Retrospective Review Process begins with a notification letter to the Agency Administrator indicating that a review has been scheduled.
The notification letter indicates the dates of the review as well as the number of IPRO staff who will be conducting the review for your agency. Upon receipt of this letter, the agency should immediately contact IPRO at the designated number if they will be requesting offsite review or an alternate location for the review. Note that medical records that will be reviewed offsite must be received at IPRO within ten (10) days of the letter date.
Within 24-48 hours of the review, IPRO will provide a case list of medical record to be reviewed. Upon arrival at the agency, IPRO’s staff requests the preselected medical records reflected on the case list. The reviewer matches the case list to the medical records provided. During the onsite review, the agency will be notified if records are missing documentation, such as signed orders, a plan of care, etc. That documentation must be provided to the IPRO reviewer before 3pm on the review date to be included in the review. Failure to provide such documentation will result in notification to the NYSDOH.
In order to conduct an accurate review it is expected that the medical record will contain information to justify the provided services at onset and throughout the duration of the provided for and billed services. This documentation must include documentation for all recertification timeframes, including disciplines both ordered and provided. Services rendered and a description of the patient’s progress and response to services is also required.
IPRO review staff is using the following criteria to conduct Medicaid CHHA reviews:
- McKesson software based InterQual Level of Care Criteria the severity of illness, intensity of service and discharge screen.
- Medicaid criteria for the onset and continued provision of care for CHHA services for the disciplines ordered and provided.