Physician Reviewer Reference Manual - Download Full Manual (974kb)

 

Table of Contents

 

1. Introduction (29kb)

    •  Mission Statement

    •  Values

    •  Background

 

2. Physician Reviewers (25kb)

    •  Physician Reviewer Qualifications

    •  Physician Reviewer Restrictions/Conflicts of Interest

 

3. Screening Criteria Used by Non-Physician Reviewers (19kb)

    •  Key Points

 

4. Physician Reviewer Responsibilities (29kb)

 

5. Physician Reviewer Documentation (25kb)

 

6. Instructions for Use of the PRAF (34kb)

    •  Elements of the PRAF

    •  Personnel Using the PRAF

 

7. Quality of Care Physician Reviewer Form (PRAF) (57kb)

    •  Professionally Recognized Standards of Care Form

    •  Approach for Review

    •  General Guidelines

    •  Do's and Don'ts of Peer Review

 

8. Utilization Review (62kb)

    •  Utilization Overview

    •  Utilization Review Process

    •  Admission Review

    •  Stapes in Admission Review

    •  Examples of Additional Factors

    •  Key Points in Review

    •  Invasive Procedure Review

    •  Coverage Review

    •  Length of Stay/Continued Stay Reivew

    •  Observation

    •  Utilization Review Flowchart

 

9. Outpatient Procedures (30kb)

    •  Formal Inpatient Admission vs. Observation Status

    •  Examples

 

10. DRG/Coding Review (59kb)

       •  DRG/Coding Overview

       •  DRG/Coding Process

       •  Definitions

       •  General Guidelines for Problem Areas

       •  Physician Reviewer Responsibilities in DRG Validation

       •  DRG Validation Review Flowchart

 

11. Quality Review (33kb)

       •  Quality Review

       •  Quality Review Process

       •  First Level Physician Review

       •  Second Level Physician Review

       •  Third Level Physician Review (Re-Review)

 

12. Response Determination Categories (RDCs) (45kb)

 

13. Sources of Quality Determination (52kb)

       •  Quality Concerns Attributable to Physician

       •  Quality Concerns Attributable to Hospital Provider

       •  Quality of Care Review Flowchart

 

14. Reconsideration/Re-Review Process (32kb)

       •  Qualifications of Reconsideration/Re-Review Physicians

       •  Review Procedures

       •  Written Notice of a Reconsidered Determination

       •  Reconsideration Review Flowchart

 

15. Administrative Law Judge (10kb)

 

16. EMTALA (20kb)

 

17. Beneficiary Complaints (20kb)

       •  Public Citizen

       •  Mediation

 

18. HINN and NODMAR (12kb)

 

19. Medicare Advantage (MA) Fast-Track Appeals (12kb)

 

20. Acute Long Term Care Hospital Review (11kb)

 

21. Hospital-Requested Higher-Weighted DRG Assignments (16kb)

 

22. Other Case Review Activities (18kb)

 

23. Worksheet Examples (63kb)

       •  Quality of Care Physician Reviewer Form (PRAF)

       •  Quality of Care Concern or "C" Categories

 

24. Example Case Studies (90kb)

       •  Utilization

       •  DRG/Coding

       •  Quality of Care Physician Reviewer Form (PRAF)

       •  Notice of Final Quality Concern Letter

 

25. Completion of Reimbursement Voucher (61kb)

       •  Physician Review Timesheet

       •  Physician Timesheet Instructions

 

26. Confidentiality (20kb)

 

27. Appendix 1 (107kb) - Guide to Review of Quality of Care Issues for Physician Reviewers Introduction for the Case Review Manager

       •  Applying Categories (Self Test)

 

28. Appendix 2 (306kb) - National Clinical Indicators

       •  Acute Myocardial Infarction (AMI) Quality Screen

       •  Heart Failure Quality Screen

       •  Pneumonia Quality Screen

       •  Surgical Infection Prevention

 

29. Appendix 3 (42kb) - Terminology

       •  Ohio KePRO Review Contacts