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HCAC & OPPC MEDICAID INPATIENT HOSPITAL SETTINGS APRIL 2012 1
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Provider Preventable Conditions PPC (Provider - Preventable Condition) OPPC (Other Provider Preventable Condition) Any healthcare setting Includes wrong surgery/invasive procedures HCAC (Health Care - Acquired Condition) Inpatient settings Medicare HACs and wrong surgery/invasive procedures 2
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Other provider-preventable condition (OPPC): A condition occurring in any health care setting that could have reasonably been prevented through the application of evidence based guidelines that meet the criteria established under 42 CFR part 447.26; Are defined to include at minimum, the three Medicare National Coverage Determinations (surgery on the wrong patient, wrong surgery on a patient, and wrong site surgery). Health care acquired condition (HCAC): A condition occurring during an inpatient hospital stay, identified as a Medicare HAC, with the exception of deep vein thrombosis/pulmonary embolism related to total knee replacement or hip replacement in pediatric and obstetric patients. Hospital-acquired condition (HAC): An undesirable condition occurring during an inpatient hospital stay. A list of conditions is identified in the Federal Register for Medicaid Regulations. Definitions 3
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Effective Date May 1, 2012 HCACs and OPPCs 4
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Review of HCACs & OPPCs that occur during hospitalizations Post payment claim-based analysis Reporting to the Medicaid agency Scope of Services 5
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Federal Register For Medicaid Regulations http://www.gpo.gov/fdsys/pkg/FR-2011-06-06/pdf/2011-13819.pdf eQHealth http://fl.eqhs.org RESOURCES 6
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Limit the number of days certified only to those preceding the event and any additional medically necessary inpatient days for services unrelated to the event HCACs & OPPCs Occurring During Hospitalizations 7
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Verification of the degree of reliability between reporting and actual claims submission. –Comparison of the information submitted to eQHealth to the “present on admission” (POA) indicator and ICD-9-CM codes on the submitted claim. Post Payment Claims-based Analysis 8
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Upon identification of a discrepancy: –A request for an electronic copy of the medical record is sent via e-mail; the record is to be submitted within 30 days of the request. Medical record received – review continues Medical record not received –Review is suspended; and –AHCA is notified Post Payment Claims-based Analysis Cont’d 9
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Frequency of occurrence by: Type of HCAC or wrong surgery/invasive procedure Provider Provider reporting reliability Provider specific patterns Reporting Results to AHCA 10
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eQHealth is responsible for reviewing HCACs and OPPCs related to hospitalizations in all hospital settings. Review Process 11
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Provider reporting during submission of review requests Identification by eQHealth during review Review Process 12
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When a HCAC or OPPC is reported by a provider or identified by a nurse reviewer, the following actions are taken: Determine if additional information is needed: No – Proceed with review Yes – Request additional information HCAC or wrong surgery/invasive procedure: No – Proceed with review Yes – Refer to second level physician reviewer First Level Review 13
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The physician reviewer may: Pend the request for additional information Consult with the attending physician Determinations: HCAC or wrong surgery/invasive procedure Whether inpatient days are solely for the treatment related to the incident Second Level Review Process 14
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Full Denial – The incident occurred on the day of admission of the recipient to the hospital and care is solely for treatment related to the incident. A recipient’s readmission (to the same hospital) occurs solely as a result of an incident related to a previous admission. Partial Denial – Inpatient days following the occurrence are solely for the treatment related to the incident. Adverse Determinations 15
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In accordance with Agency policy, any party involved in the case may request a reconsideration of an adverse determination. Requests for reconsideration will be reviewed by a physician reviewer not involved in the original case review. Reconsiderations 16
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Providers must report the: Date of the occurrence Nature of the specific event Applicable ICD-9-CM code Provider Reporting Requirements - eQSuite 17
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eQSuite 18
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eQSuite 19
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eQSuite 20
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eQSuite 21
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eQSuite 22
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eQSuite 23
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eQSuite 24
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Customer Service 855-444-3747 Nancy Calvert Director, Provider Education & Outreach ncalvert@eqhs.org RESOURCES 27
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