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QIO TRANSMITTAL SERIES ISSUE: Physician Consultant Review - Printable
pages The Foundation’s Case Review Specialists
perform an initial screening review of all cases selected for review. Foundation Physician Consultants review
all cases where a Case Review Specialist raises a potential concern about the
medical necessity of the admission or a procedure performed or if there is a
question about the DRG assignment that involves medical judgment rather than
technical coding issues. Because
notices of noncoverage involve a denial of benefits, all cases involving
notices of noncoverage are reviewed by Physician Consultants. Physician Consultants also review all
cases where a quality of care concern is raised by a Case Review Specialist
or where a beneficiary/beneficiary representative has requested a review of
the quality of care provided. The Foundation’s Physician Consultant
roster consists of over 200 physicians from a variety of specialties who are
licensed, actively practicing physicians in When a case is referred for physician
review, the Physician Consultant selected will be a physician who practices
in the same state as the attending/involved physician. To the extent possible, the Physician
Consultant will also be of the same specialty as the physician under review. If a matching specialty is not available
in the same state, the case will be referred to a Physician Consultant
practicing in the same state in a closely related specialty. The Physician Consultant receives the
medical record photocopy provided by the hospital for review along with the
questions raised by the Case Review Specialist. If the Physician Consultant confirms a potential concern, the
hospital and attending physician will be notified and given twenty days to
respond to the notice. (Please refer
to the Transmittal Issues on the Utilization, Quality or DRG review processes
for specific details about these processes.)
It is recommended that hospitals coordinate their responses with the
attending physicians. It
is important to include the following information in the response: · Patient identifying information, including QIO
claim key number · Additional documentation from physician office
records, if appropriate · Specific rational justifying the need for the
admission or procedure, the level of care determination, the DRG assignment
or the quality of care provided · Request for discussion with the Physician
Consultant, if desired, including contact information and availability. The Physician Consultant receives any
additional information/response provided by the response due date, along with
the medical record and case review information, to make a final
determination. If the QIO Physician Consultant, after reviewing the case with
the additional information provided, upholds the original decision to confirm
a concern, a notice to this effect, outlining further appeal rights (denials)
or rereview rights (DRG changes or quality concerns), will be issued. If the QIO Physician Consultant reverses
the original decision, a notice to this effect will be issued. If no response is received, the Foundation
upholds the original decision. October
2003 Back
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Copyright © 2005 Northeast Health Care Quality Foundation, all rights
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