www.ohiokepro.com
Vol. 3 No. 1
Winter 2004-2005
New Assistant
Medical Director
Joins Ohio KePRO
AHRQ Offers First Web-based
Patient Safety Resource
In October, Ohio
KePRO hired John C.
Westerbeck, MD, as
its new Assistant
Medical Director for
the Review Department.
Dr. Westerbeck comes
to us from West
Medical in Massillon,
Ohio, where he is a
practicing internist. He
received his bachelor's
degree from Xavier University and his medical
degree from Nor theastern Ohio Universities
College of Medicine.
Dr. Westerbeck brings with him a wealth of
knowledge in the quality arena as well as prior
peer review experience. He is active in the Stark
County Medical Society and Ohio State Medical
Association, as well as in community issues
impor tant to public health.
Dr. Westerbeck recently spoke with former
Depar tment of Health and Human Ser vices
Secretar y Tommy Thompson on his recent trip
to Stark County regarding electronic medical
records, distribution of influenza vaccine, and
the role of quality improvement effor ts in the
face of budgetar y constraints. In his role as
Assistant Medical Director, Dr. Westerbeck will
be working in many areas, including acting as
an advisor for review coordinators on clinical
issues, physician reviewer training, and
Interrater Reliability studies.
T
features readers' polls, quizzes
and other multimedia elements.
Practicing physicians may obtain
continuing medical education (CME)
credit by successfully completing
the spotlight case and its questions,
and trainees can receive certification.
A PowerPoint version of the spot-
light case is available to download
for educational use, such as in
student teaching conferences or
residents' repor ts.
he Agency for Healthcare Research
and Quality (AHRQ) Web M&M site
is the nation's first Web-based patient
safety resource and journal. The Web
site has the following features:
Ever y month, five interesting cases
of medical errors and patient safety
problems--one each in medicine,
surger y/anesthesia, obstetrics-
gynecology, pediatrics, and other
fields such as psychiatr y, emergency
medicine, and radiology--are posted.
Every month, five interesting cases
of medical errors and patient safety
are posted.
Please Note:
Ohio KePRO's office will be closed on
Februar y 21, 2005, in obser vance of
Presidents' Day.
These cases are submitted
anonymously through the Web site.
Writers of cases selected for posting
receive an honorarium. Cases are
compelling and raise key issues
about patient safety and systems
improvement.
One of the cases each month is
expanded into a "Spotlight Case"--
an interactive learning module that
The remaining four cases each
month are followed by a commentary,
written by an exper t in the relevant
clinical or patient safety field. The
format marries an evidence-based
approach with anecdotal observations
and qualitative analysis to produce
a lively discussion, which also
takes advantage of the graphic
capabilities of the Internet.
Continued on pg. 2
Standardized Review Process
Promotes Accuracy
New KePRO
CEO Named
T
he case review process is a key
component in Ohio KePRO's production
of high quality work. Variability in the
application of this review process may result
in inconsistent review outcomes. Therefore,
Ohio KePRO follows a standardized review
process, which is applied consistently by
reviewers. This promotes uniform reviews
that are less prone to inaccuracy.
Consistency across reviews depends on
process standards, clearly applied steps to
reaching a conclusion (outcome), and, for
physician review, clinical judgment. It is
essential to measure the consistency and
reliability of the review process Internal
Quality Control (IQC)/Interrater Reliability
(IRR) and outcomes.
Ohio KePRO follows
a standardized
review process.
Internal quality control
Ohio KePRO uses the following Internal
Quality Control (IQC) process: (1) A 10
percent char t sample is chosen from all
review types for IQC review; (2) A por tion of
this sample is then sent out for IRR. We
send the original PRAF (physician reviewer
assessment form) along with the medical
record to a same-specialty physician reviewer.
These results are compared to see if the
two reviewers reached the same conclusion.
This process helps to ensure that all
aspects of the review process are captured
appropriately. It also helps us identify areas
for improvement.
The IQC/IRR process has helped with
formulating better PRAF questions, physician
reviewer training and formatting the PRAF
form. This process will be mandator y for all
QIOs in the 8th Scope of Work.
Two IRR studies
Ohio KePRO is currently involved in two
Centers for Medicare & Medicaid Ser vices
(CMS) IRR studies. Lumetra, the California
Quality Improvement Organization (QIO), is
leading an IRR Extension Project that focuses
on the accuracy and consistency of physician
admission necessity cases across QIOs.
The IRR study involves the par ticipation of
a representative group of QIOs defined by
geography, state size, prior involvement
within the IRR pilot, and the use of IRR with
InterQual criteria. The purpose is to identify
a possible set of characteristics that might
help QIOs determine what type of physicians
might make the most reliable reviewer. By
comparing QIO PR results with an exper t
panel who will review the same cases, and
outline their rationale in detail, we hope to
identify the issues in admission necessity
that might be influenced by QIO training,
and what issues are not in the control of
the QIO.
The other study is an Admission Review
Consistency Study. This is a collaborative
on physician review reliability among four
states--Missouri, Michigan, West Virginia
and Ohio, headed by the Missouri Quality
Improvement Organization. The purpose of
this project is to investigate the degree and
causes of intra- and inter-QIO variations in
Medicare inpatient admission determinations
and to assess whether implementing a set
of guidelines developed to reduce the
variations may assist the reviewers in
making more uniform decisions.
On September 1,
2004, Joseph A.
Dougher became
Chief Executive
Officer for KePRO,
the parent company
of Ohio KePRO.
Joe joined KePRO
in 1992. He
ser ved as KePRO's
Chief Financial
Officer (CFO) since 1999, working
extensively to help KePRO identify new
healthcare oppor tunities and markets
within a rapidly changing industr y.
"Joe has established a strong leadership
reputation at KePRO, and is a highly
regarded member of senior manage-
ment," said Donald Harrop, MD, KePRO
President. "I look forward to working with
Joe over the next few months to ensure
a smooth transition of responsibilities."
Joe succeeds Dr. Harrop, who had been
acting CEO for nine months. Dr. Harrop
remains as President of KePRO.
KePRO, in its 20th year in business,
is one of the nation's leading quality
healthcare solution companies, providing
independent medical review, utilization
management, quality improvement
studies, peer review, and other ser vices
to healthcare organizations. The company
is headquar tered in Harrisburg, PA, with
offices in Cleveland, OH (Ohio KePRO);
Tampa, FL; and York, PA.
Ohio KePRO Review
Depar tment Contacts
Contact the following Ohio KePRO Review
Depar tment staff at 1-800-385-5080 for
questions per taining to:
AHRQ Offers First Web-based Patient Safety Resource
(cont. from page 1)
led by Drs. Bob Wachter and Kaveh
Shojania at the University of California,
San Francisco, with the technical suppor t
of DoctorQuality, the Philadelphia-based
healthcare quality company. Erin Har tman
is the Managing Editor. An editorial board
and advisor y panel, comprised of exper ts
in the relevant patient safety and clinical
disciplines, guide the editorial team.
The Web site includes a users forum on
which readers can post and react to
comments that relate to the cases.
The Web site also provides links to
other resources and interesting facts
about patient safety, medical errors and
healthcare quality.
The AHRQ Web M&M site seeks to better
prepare physicians to take a proactive role
in changing our healthcare system. It is
funded by the AHRQ, and edited by a team
Ohio KePRO encourages you to visit this
interesting and educational Web site at
www.webmm.ahrq.gov
Review Decision
(Involving Medical Judgment)
Dr. David A. Bitonte, ext. 2117;
Dr. John Westerbeck, ext. 2227
Physician Credentialing
Liz Paduano, ext. 2222
Criteria/Quality Screen Questions
Christine Reid, ext. 2162
Scheduling Review for Ohio KePRO,
Char t Pick Up/Drop Off, Mail Review
Policy
Deb Arensberg , ext. 2125
Physician Reviewer Training Needs
Christine Reid, ext. 2162
Coding Review Questions
Carole Tarbuck, ext. 2134
2
URAC Peer Review Standards
URAC accreditation requires ongoing education of KePRO staff and consultants (peer reviewers) on
per tinent standards or changes. This newsletter provides an introduction to the URAC accreditation
process and standards. Peer reviewers will be kept informed of the process through subsequent
newsletters, contract training, and information submitted with case reviews.
G
overnment (federal/state) organizations and commercial
insurers are requiring URAC accreditation to ensure consistency
and fairness in the review process. An organization with URAC
accreditation strives for a fair and impar tial review process that is
of benefit to both patients and physician grievances. What does
this mean for KePRO peer reviewers? Will the process or
requirements for review change?
Health Utilization Management (UM) standards that apply to the
peer review process are addressed in URAC Core standards 20 and
42, and in Health UM standards 11, 20-21 and 22.
confidentiality agreements in the process of providing their determi-
nations.
UM standards 20-21 specify the peer reviewer qualifications,
availability, and turnaround times associated with specific types of
review. Our credentialing, training and monitoring processes estab-
lish the reviewers' qualifications. KePRO medial directors use this
information to select a peer reviewer to render an opinion about
the medical condition, procedures, and treatment under review. It is
essential that the reviewer not only be licensed and board cer tified
in the appropriate specialty, but also have experience or knowledge
regarding the treatment under review.
Core standard 20 requires a senior clinical staff person in the
organization to provide guidance, be responsible for, and have periodic
consultation with, practitioners in the field. KePRO's medical
directors for each contract have, and will continue to fulfill, this
obligation through monitoring of peer reviewer repor ts for accuracy,
quality, and interreviewer reliability, and through communications
with peer reviewers, as necessar y.
UM standard 22 requires health professionals conducting the peer
review be available, by telephone or in person, to discuss review
determination with the attending physician or other ordering
providers. Currently, many KePRO contracts do not require peer
reviewer interaction with the ordering physician; however, we antici-
pate increased inclusion of this standard as more government and
commercial contractors require that URAC standards be followed.
Core standard 42 addresses the impor tance of the formal appeal
resolution process to include: written notification of the determination
with an explanation of the reason for the determination; notification
of the process for seeking further review, if available; and a reasonable
specified time frame for resolution and response. This standard
requires the peer reviewer's repor t to contain not only the determi-
nation of approval or denial on an appeal, but to elaborate on the
rationale for that decision. Peer reviewers will get specific questions
to address, and must submit the response within the time frame
specified by the KePRO contract. Expedited determinations are
usually completed within 2448 hours, whereas standard reviews
may range from 7 to 30 days. KePRO's expectations for peer
reviewers, the essence of Core standard 42, is clear rationale for
the reviewer's decision and timeliness, both of which are principle
elements of a quality peer review.
KePRO has always expected independent and objective peer review
on all cases submitted for determination; URAC accreditation
provides reaffirmation of those expectations. Peer reviewers should
see little process change except for ongoing education regarding
evolution of case review.
UM standard 11 requires patient information be kept confidential,
used solely for the purposes of the review determination, and shared
only with those who have authority to receive such information.
Peer reviewers have been, and will continue to be, expected to
comply with confidentiality and HIPAA standards, and to sign
Credentialing Process Improved
K
ePRO's electronic peer reviewer database and credentialing
process have undergone substantial improvements. We use the
electronic database in all of our offices to track key credentialing
indicators and schedule cases. KePRO South (Tampa, FL) and Ohio
KePRO (Seven Hills, OH) will recredential peer reviewers whose
primar y clinical practice and licensure are in their respective
states. The corporate office in Harrisburg will recredential the
rest of the nation.
Ohio licensed physicians, if you have credentialing questions, call
216.447.9604 to speak with:
Elizabeth Paduano, Credentialing Coordinator, ext. 2222
(epaduano@ohqio.sdps.org)
David A. Bitonte, DO, MBA, FAOCA, Medical Director, ext. 2117
(dbitonte@ohqio.sdps.org)
URAC accreditation will not change KePRO's credentialing process
since our current procedures require copies of current licensure
and board cer tifications upon initial credentialing and subsequent
recredentialing. KePRO's credentialing coordinators track license
and board cer tification expiration dates using an electronic data-
base; if current license and/or cer tification cannot be verified at
the appropriate state and board Web site, you will be contacted to
provide the current information.
All other licensed physicians, if you have credentialing questions
call 800.222.0771 to speak with:
Laura Brown, Credentialing Coordinator
(lbrown@kepro.org)
Frank P Castrina, MD, Medical Director, ext. 2115 .
(fcastrin@kepro.org)
Florida licensed physicians, if you have credentialing questions,
call 813.262.9441 to speak with:
Herber t U. Pegues II, MD FAAFP Medical Director ,
(HPegues@keprosouth.com)
Dr. Marcelino Oliva
(MOliva@keprosouth.com)
Carlene Ashley DO
(CAshley@keprosouth.com)
URAC Core Standard 15:
Addresses verification of current licensure and credentials of
licensed cer tified personnel/consultants upon hire, and
thereafter no less than ever y 3 years; and implementation of
corrective action in response to adverse changes in licensure
or cer tification status.
Rock Run Center, Suite 100
5700 Lombardo Center Drive
Seven Hills, OH 44131-2545
Tel: 216.447.9604
Fax: 216.447.7925
Ohio KePRO Provider QIC Line--Your Quality Improvement Connection: 1-800-385-5080
Medicare Help Line: 1-800-MEDICARE (1-800-633-4227) · www.ohiokepro.com · e-mail: review@ohqio.sdps.org
MATERIAL FEEDBACK SURVEY
Ohio KePRO is continuously working to improve the quality of care
delivered to Medicare beneficiaries. We offer innovative products and
ser vices, and educational resource materials to encourage and
suppor t continuous quality improvement.
In an effor t to improve the effectiveness of our materials, we would like you to take 3 to 5
minutes to complete the following sur vey. Par ticipation is voluntar y and all answers are
confidential. Please fill out this sur vey at your convenience and fax to: 216.447.7925, or return
it using the self-contained mailer. We appreciate your feedback.
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Ohio KePRO
Rock Run Center, Suite 100
5700 Lombardo Center Drive
Seven Hills, Ohio 44131
Tel: 216.447.9604
Fax: 216.447.7925
www.ohiokepro.com
ATTN: Marketing & Communications Dept.
ATTN: MARKETING & COMMUNICATIONS
OHIO KEPRO
ROCK RUN CENTER
5700 LOMBARDO CENTER DRIVE STE 100
SEVEN HILLS OH 44131-9941
Case Review Staff Spotlights
Debra Schuster, Review Coordinator, has been with Ohio KePRO since
Januar y 2004. Deb is an LPN with extensive long-term care experience.
She is primarily involved with beneficiar y complaints and is also cross-
trained to perform HIA (Higher-weighted DRGs) and CDAC (Clinical Data
Abstraction Center) reviews. In addition, Deb rotates with the other
reviewers in doing MA (Medicare Advantage) fast track reviews during
the week and on weekends. Deb has more than 15 years experience in
staff development, QI and Medicare Par t B DME.
In her spare time, Deb is also the state coordinator for the American
Brittany Rescue. Her duties there include fostering and transpor ting the dogs, coordinating
the volunteers and reviewing applicants for adoption.
Physician Reviewer
Reference Manual
Recently you received the new Physician
Reviewer Reference Manual. Inside you
will notice that Ohio KePRO has made
changes to some of our processes as
well as our forms. The following are two
of the most frequently asked questions
we have received regarding the changes:
Although Deb is the newest member of our team, we can't remember how we managed
without her!
Question: There is no place to put my
time on the new PRAF form.
Should I squeeze it in next to
my signature?
Jackie Haskin is our Records Clerk, but she does so much more! She has been with Ohio
KePRO since Februar y 2000. Her responsibilities include, but are not limited to, managing
our records room, receiving incoming records from the CDAC (Clinical Data Abstraction
Center), answering the beneficiar y Help Line, Hospital Issued Notice of Noncoverage (HINN)
monitoring, records retention, requesting the Higher-weighted DRG char ts (HIA), creating
folders, and working our receptionist desk. Jackie came to Ohio KePRO from University
Hospitals of Cleveland where she worked in medical records. Her duties included creating
char ts for new admissions, release of information and preparing incomplete records for
review. Jackie's hobbies include traveling and the ar ts. She is a great asset to our team.
Her extension is 2209 should you ever need to reach her.
Additional Reviews Coming Soon
Answer : No. The only place you need to
show your time is on the time
sheet. The scheduler will have
marked on the time sheet how
many of each type of case you
received, so make sure you are
listing your minutes next to the
appropriate number of cases.
Question: I mailed back the PRAF form
and time sheet with the
Medical Record. A day later
someone called and said I
should have faxed it first. Is
this necessar y on all char ts?
A
s many of you are aware, Ohio KePRO
has been the Independent Review
Entity (IRE) for Medicare beneficiaries in
Ohio who are enrolled in a Medicare
Advantage (MA) program since Januar y 1,
2004. MA enrollees who want to appeal
their discharge from a skilled nursing facility
(SNF), home health agency (HHA), or a
comprehensive outpatient rehabilitation
facility (CORF) now appeal these decisions
through Ohio KePRO.
The fast track appeal begins when the
Medicare beneficiar y or his/her
the review coordinator notifies the plan, the
provider, the practitioner, and the Medicare
beneficiar y (or his or her representative).
The Centers for Medicare & Medicaid
Ser vices (CMS) mandates that Ohio KePRO
be available seven days a week during
normal business hours for these appeals.
Will apply to all Medicare beneficiaries
As of July 1, 2005, this review process will
apply to the entire Medicare population. A
Medicare beneficiar y who is in traditional
Medicare will now follow the same process
as the MA enrollees. Ohio KePRO anticipates
Answer : Yes, our contract with the
Centers for Medicare & Medicaid
Ser vices (CMS) calls for strict
time frames for review activities.
Faxing back the PRAF gives us
a head star t on getting the
infor mation into our computer
system and star ting to draft the
appropriate letter s that go
with your response. It is not
necessar y to fax back your time
sheet, as we cannot issue
payment based on a photocopy/
fax copy. For audit purposes,
our finance depar tment will only
issue payment based on original
time sheets.
MA enrollees who want to appeal their
discharge from a SNF, HHA or CORF
now appeal these decisions through
Ohio KePRO.
an increase in fast track appeals as a result.
Currently, only 10 percent of Ohio Medicare
beneficiaries are enrolled in an MA program.
representative telephones Ohio KePRO to
initiate the review process. The review coor-
dinator notifies the plan and contacts the
provider and practitioner for their input.
Once the medical records arrive via fax, the
review coordinator telephones one of Ohio
KePRO's physician reviewers and conducts
a telephone review of the ser vices received
to determine if continuing ser vices would
be appropriate. Once a decision is made,
If you currently practice in the nursing
home or CORF settings and would be
willing to conduct these reviews, please
contact Elizabeth Paduano at
216-447-9604, Ext. 2222.
We also have added the manual to the
Ohio KePRO Web site at
www.ohiokepro.com. Once you go to the
Web site, click on "Providers" in the left-
hand column, then click on "Physician
Reviewers." The Physician Reviewer
section is password protected. When
prompted, the user name is liz, the
password is liz2222. We will continue to
add information into the Physician Review
section of our Web site.
As always, if you ever have a question, do
not hesitate to contact our office at
1-800-385-5080.
3
KePRO Applying For URAC Health Utilization
Management Accreditation
K
ePRO is applying for Health Utilization
Management Accreditation from
URAC, a Washington, DC-based healthcare
accrediting organization that establishes
quality standards for the healthcare industr y.
URAC's Health Utilization Management
Accreditation standards provide assurance
to patients, providers, purchasers, regulators,
and employers that the practices of the
organization performing these ser vices are
fair and equitable for all par ties.
KePRO's utilization management ser vices
include:
Medical necessity, appropriateness
and coverage determinations.
Quality of care reviews.
DRG/coding validation.
Fraud and abuse assessments.
the rapid changes in the healthcare system,
and provide a mark of distinction for health-
care organizations to demonstrate their
commitment to quality and accountability.
Through its broad-based governance
structure and an inclusive standards
development process, URAC ensures that
all stakeholders are represented in setting
meaningful standards for the healthcare
industr y. For more information, visit
http://www.urac.org.
"By applying for accreditation under URAC's
Health Utilization Management (UM)
standards, we can demonstrate to various
stakeholders a commitment to quality UM
processes," said Donald Harrop, MD,
President of KePRO.
The URAC Health Utilization Management
standards establish consistency in UM
processes. The standards ensure that
appropriately trained clinical personnel
conduct and oversee the utilization review
process, that a reasonable and timely
appeals process is in place, and that
medical decisions are based on valid
clinical criteria.
Identification of improvement
oppor tunities.
Innovative technology and repor ting.
Commitment to quality and accountability
"By choosing to seek URAC Health Utilization
Management Accreditation, KePRO has
displayed leadership through a commitment
to quality and accountability," said Garr y
Carneal, URAC President and CEO.
URAC, an independent, nonprofit organization,
is a leader in promoting healthcare quality
through accreditation and cer tification
programs. URAC's standards keep pace with
Ohio KePRO Review Depar tment Staff
David A. Bitonte, DO, MBA, FAOCA Medical Director
John C. Westerbeck, MD Assistant Medical Director
Jennifer Bitterman, RHIA, MBA Review Manager
Donna Ugan, RN Review Super visor
Martie Truby BSEd, RHIA Review Super visor
Carole Tarbuck, RHIT Review Specialist
Kim Storms, LPN Review Specialist
Christine Reid, LPN Review Specialist
Liz Paduano Administrative Assistant
Deb Arensberg Review Assistant
Jackie Haskin Records Clerk
Linda Holland, LPN Review Coordinator
Deb Kesterson, RN, BSN Review Coordinator
Jan Papp, RN Review Coordinator
Publication No. 4201-OH-001-1/2005. This material was prepared by Ohio KePRO, the Medicare Quality
Improvement Organization for Ohio, under contract with the Centers for Medicare & Medicaid Ser vices (CMS), an
agency of the U.S. Depar tment of Health and Human Ser vices. The contents presented do not necessarily reflect
CMS policy.
Rosann Pasko, MS Marketing Inter vention Specialist
Barb Rivera, RHIA, RRT Review Coordinator
Deb Schuster, LPN Review Coordinator
Christine Lerz, CPHQ Analyst
Mona Wendell, RN, MBA QI Project Leader
Medical Editor : David A. Bitonte, DO, MBA, FAOCA
Executive Editor : Suzana C. Iveljic, MBA
Editor : Robert A. Feigenbaum, MS
T H E W I N T E R 2 0 0 4 - 2 0 0 5 I S S U E O F T H E P H Y S I C I A N ' S A DV I S O R H A S A R R I V E D !
The Newsletter of the Ohio KePRO Review Department
Rock Run Center, Suite 100
5700 Lombardo Center Drive
Seven Hills, OH 44131-2545
Tel: 216.447.9604
Fax: 216.447.7925
First-Class Mail
U.S. Postage Paid
Cleveland, OH
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