Administrative Memos

200402

FROM: Theodore O. Will, Chief Executive Officer
DATE: Mar 15, 2004
SUBJECT: MEDICAID REVIEW DETERMINATION PROFILES: OCTOBER 1, 2003 - DECEMBER 31, 2003
IPRO CONTACTS:

Michael Lebert, Director, Data Analysis & Evaluation, Ext. 630

Enclosed are three (3) reports that describe the findings for Medicaid utilization, DRG, and quality reviews conducted by IPRO under the Medicaid Case Payment System. These reports cover the review period October 1, 2003 through December 31, 2003. The three reports included are as follows:

• A 1-page summary of the review findings for the time period.
• A detailed case listing with specific review determination results for the time period.
• A 1-page summary of the review findings for all hospitals in your peer group, for comparison purposes.

The following guide provides an explanation of each of the four (4) categories of review findings listed on the summary Review Determination Reports:

• The retrospective review category includes cases, which may have been randomly selected or selected for specific utilization criteria including: readmission and transfers, short stay, UR and random and focused reviews. This category also includes the results of quality of care reviews, performed for a sample of cases with in-hospital mortality and/or complication codes, as identified from the paid claims data.
• The DRG review category includes cases selected specifically for DRG validation.
• The enhanced UR Program review includes the review of admissions to exempt (Pysch and Rehab) units in acute care facilities.
• The other review category includes cases awaiting alternative level of care (ALC) placement for more than two (2) days on a prepayment basis; cost outlier review, discharge review (IPRA); auto denials (category not in use during this time period); state referred cases and preadmission review.

The following definitions are provided for each column heading included on the Summary Review Determination Report.

1. Universe of cases is the number of Medicaid patients discharged and billed by the hospital during this time period as per the adjudication claims tape provided by MMIS.
2. The cases selected are cases selected for IPRO review. Not all of the cases that are selected are reviewed in the current quarter. Some selected cases may be reviewed in a subsequent quarter.
3. Cases completed include all case reviews completed during the reported quarter and may include cases selected for review from a previous quarter.
4. Cases approved are the number of cases with no utilization, DRG or quality concerns identified after review has been completed.
5. Percent of cases approved is the quotient of cases approved divided by the number of cases completed.
6. Cases denied are the number of cases with a confirmed utilization, DRG, or quality concern. These concerns reflect the final decision made during the review quarter.
7. Percent of cases denied is the quotient of cases denied divided by the number of cases completed.
8. There are five types of denials. These include admission, continued stay (LOS), DRG, quality, and technical denials. A technical denial is issued when all or parts of the medical record are unavailable for review. The sum of these denials may not equal the total number of case denials due to instances where the cases receive more than one (1) type of denial, e.g., quality and DRG.

The Case Listing Report is a list of cases of retrospective reviews with reviews completed during the reporting period. The case listing includes the case number, patient's name, admission and discharge dates, the IPRO batch number and the final review determinations (for Admission, LOS, DRG and Quality) and an indication if the case was technically denied. Additionally, if an appeal was made on a denied case, results of the appeal are included underneath the final determination results for that case. Case listings are generated only for the first three review categories (i.e., Retrospective, DRG and Enhanced UR Program).

Should you have any questions or comments about these reports or the reporting of review findings, please feel free to contact Michael Lebert, Director, Data Analysis & Evaluation, at (516) 326-7767, extension 630.