DCS Comprehensive Health Plan

Peer Review

Policy Statement

DCS Comprehensive Health Plan (DCS CHP) participates in a peer review process to address provider quality of care and service issues.

Scope

The Peer Review process addresses matters where there is evidence of a quality deficiency in the care or service provided, or the omission of care or service, by a participating or nonparticipating health care provider. These issues are addressed in a confidential forum by peers.

Definitions

DCS CHP Quality Management Team: clinical staff that research and evaluate Quality of Care (QOC) concerns; provide oversight of credentialing, monitor compliance with required quality standards and Contractor Corrective Action Plans (CAPs).

National Committee Quality Assurance (NCQA): is a private, 501 (c)(3) not-for profit organization dedicated to improving health care quality.

Peer Review: process by which a health care provider, or committee of providers, examines the work of a peer and determines whether the provider under review has met accepted standards of care in rendering medical services.

Quality of Care (QOC): A suspected deviation from provider performance, clinical care, or outcome of care that requires further investigation to determine if an actual Quality of Care issue exists.

Policy

DCS CHP requires its contracted MCO to conduct Peer Review as a function of the Credentialing and Quality of Care activities in the contract. This function is not a delegated function but rather a collaboration between the DCS CHP and the contracted MCO. The Peer Review process addresses the provision of appropriate care and quality of services provided by health care professionals and organizational providers regardless of provider location or network participation. The goal is to improve the quality of care to DCS CHP members. The DCS CHP Quality Management and Performance Improvement (QM/PI) function area participates and assists with the peer review process.

Procedure

Identification and Initial Quality Review

Potential Quality of Care (QOC) concerns are referred to the contracted MCO’s Quality Management Unit for initial screening and triage review and systematic examination. QOC findings are reviewed and recommendations are addressed at the MCO’s Peer Review Committee meetings as appropriate.

QOC issues reviewed in the Peer Review Committee may be identified through:

• Members and/or out of home caregivers/health care decision makers;

• Custodial agency representatives;

• Health care providers;

• DCS CHP staff;

• Community service agencies;

• Licensing agencies;

• Governmental agencies, including Arizona Health Care Cost Containment System (AHCCCS);

• Concurrent, prospective, and retrospective utilization reviews;

• Care Coordination activities;

• Facility site reviews;

• Claims and encounter data;

• Pharmacy utilization data;

• Medical record audits; and

• Complaints/Grievances and Appeals.

Matters appropriate for Peer Review include, but are not limited to:

• Cases where there is evidence of deficient quality;

• An omission of the care or service provided by a participating or non-participating physical health care or behavioral health care provider;

• Questionable clinical decisions, lack of care and/or substandard care;

• Inappropriate interpersonal interactions or unethical behavior, physical, psychological, or verbal abuse, neglect, and or exploitation of a member, family, staff, or other disruptive behavior demonstrated by a provider;

• Allegations of criminal or felonious actions related to practice;

• Issues that immediately impact the member and that are life threatening or dangerous; or

• Issues that have the potential for adverse outcome.

Peer Review Committee

The contracted MCO facilitates a Peer Review Committee for review of quality of care issues and as part of the credentialing process (see credentialing procedures outlined in DCS CHP policy HS-QM-01 Individual Provider and Group Credentialing).

The Peer review committee makes appropriate recommendations to the contracted MCO’s Peer Review Chairperson who is responsible for implementation of the committee’s recommendations. The DCS CHP CMO or designee participates in the contracted MCO peer review committee. The contracted MCO is required to report adverse action decisions by the Peer Review committee to DCS CHP within 24 hours of the decision.

DCS CHP requires that the Peer Review Committee evaluate provider QOC concerns, as well as other provider related quality concerns, based on all information made available through the Quality Management processes, and determining appropriate action including, but not limited to:

• Education;

• Reduced or revoked credentials;

• Limit on new member enrollment;

• Sanctions; and/or

• Other corrective actions.

DCS CHP requires that the Peer Review Committee be comprised of:

• Contracted MCO Chief Medical Officer or designated Medical Director as Chairperson;

• DCS CHP Chief Medical Officer or designee;

• Providers of the same or similar specialty that serve AHCCCS members, including medical and behavioral health providers to participate in review and recommendation of individual peer review cases. If a specialty being reviewed is not represented, a peer of same or similar specialty may provide external consultation;

• Ad Hoc Members as needed (chosen by the Chairperson).

Peer Review meetings occur at a minimum quarterly or more frequently, as needed.

The Peer Review Committee recommends appropriate actions regarding initiation of referrals for further investigation or action to:

• Department of Child Safety (DCS);

• Adult Protective Services (APS);

• Arizona Department of Health (ADHS) Services Licensure Unit;

• National Practitioner Data Bank;

• Law enforcement;

• Attorney’s General Office;

• Office of Inspector General (OIG),

• Appropriate regulatory agency or board, and

• AHCCCS.

Peer Review Committee determinations and recommendations including suggested corrective actions are selected appropriately for the level of severity, as specified in the AHCCCS Medical Policy Manual (AMPM).

Peer Review Committee members are required to sign a confidentiality and conflict of interest statement at each Peer Review Committee meeting. If attending remotely, the committee members may sign a confidentiality statement electronically or refer to their annual conflict of interest statement that is kept on file. Committee members do not participate in Peer Review activities if they have a direct or indirect interest in the Peer Review outcome, or conflict of interest.

DCS CHP requires that adverse actions taken as a result of the Peer Review Committee are implemented by the MCO and reported to DCS CHP and AHCCCS Quality Management Unit within 24 hours of an adverse decision being made. Initial notification may be verbal, followed by a written report in one business day.

External Peer Review/Consultation

DCS CHP requires that External Peer Review is facilitated by the contracted MCO. Circumstances that require external review include:

• Need for specialty review when there are no medical staff members within the Peer Review Committee of the same or similar specialty;

• Peer Review Committee cannot make a determination and requests external review;

• Dealing with ambiguous or conflicting recommendations from internal reviewers, or when there does not appear to be a strong consensus for a particular recommendation.

Documentation and Confidentiality

DCS CHP requires that:

• All findings and information used in the Peer Review process are documented in confidential minutes.

• Peer Review Committee reports, meetings, minutes, documents, recommendations, and participants are kept confidential except for implementing the recommendations made by the Peer Review Committee.

• Findings and information used in the Peer Review process are secured within the MCO Department of Quality Management and Process Improvement and not discussed outside of the Peer Review process.

• High level Peer Review summaries on cases are maintained as part of the original QOC file.

• Information is also filed in the provider’s credentialing files and reviewed at the time of the provider re-credentialing process.

Evaluation of provider-specific clinical care is not shared with other DCS CHP function areas, members, member caregivers/families, external agencies or other committees.

The contracted MCO is responsible for relaying the findings of the Peer Review Committee to the provider in question.

The Peer Review chairperson or the DCS CHP Chief Medical Officer may follow up on medical quality complaints directly with members/caregivers, or delegate follow up communication for complaint resolution. Results of Peer Review activities are not shared during these communications.

Peer Review Committee is the final review in the credentialing process for all credentialing and re- credentialing files. Adverse actions taken as a result of Peer Review Committee are communicated to DCS CHP within 24 hours of the decision.

DCS CHP requires that details regarding Peer Review discussions are maintained securely by the contracted MCO.

DCS CHP requires that Peer Review documentation be made available for review, and be provided to DCS CHP and AHCCCS upon request for the purposes of quality management, monitoring, and oversight.

Communication to Involved Provider

Sub-standard findings and recommendations made by the Peer Review Committee are communicated to the provider within ten days of the determination. The appeal process is also included in the communication.

Appeal Rights

A provider has the right to appeal a decision made based on the recommendation for actions related to quality of care or utilization. The appeal process is managed by the contracted MCO. (See MC policy 8000.15D Fair Hearing).

Monitoring and Reporting

The DCS CHP CMO or delegate participate in the contracted MCO’s Peer Review committee as part of the quality and credentialing process requirements. Adverse actions determined by the Peer Review Committee are reported to DCS CHP within 24 hours of the decision.

Findings of the Peer Review Committee, that recommend initiation of referrals for further investigation review or action, are reported to the appropriate regulatory agency within 24 hours after the determination. Regulatory agencies include:

• Department of Child Safety (DCS);

• Adult Protective Services (APS);

• Arizona Department of Health (ADHS) Services Licensure Unit;

• National Practitioner Data Bank;

• Law enforcement;

• Attorney’s General Office;

• Office of Inspector General (OIG),

• Appropriate regulatory agency or board, and

• AHCCCS.

Adverse actions taken as a result of the Peer Review Committee are reported to AHCCCS Quality Management within 24 hours of an adverse decision being made.

Peer review documentation Committee reports, meetings, minutes, documents, recommendations, and participants are kept confidential with the exception for implementing recommendations made by the Peer Review Committee.

A summary of Peer Review Committee activities may be presented to the QM/PI Committee.

The performance of entities and the quality of services provided are monitored on an ongoing basis performed by the MCO. DCS CHP provides oversight activities for monitoring including, but not limited to:

• Utilization,

• Member and provider satisfaction,

• QOC concerns, and

• Complaints.