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acute

As the federally-designated healthcare quality improvement organization for Massachusetts, Masspro is committed to working with providers to ensure that patients receive the highest quality of care.

Masspro has been partnering with the Executive Office of Health and Human Services (EOHHS), specifically the Office of Medicaid, since 1993. Masspro’s partnership includes utilization management programs (UMPs) and quality improvement projects (QIPs) designed to assist the acute care facilities improve the care provided to MassHealth members.

Utilization Management Programs
UMPs evaluate the medical necessity, appropriateness, timeliness and quality of healthcare services provided in both the inpatient and outpatient acute hospital settings. By consistently applying the most up-to-date standards of care, Masspro uses its structured UMP review process model to both assess the delivery of healthcare services and to identify opportunities for process improvement and provider education needs.

Masspro performs three types of reviews for acute hospitals throughout Massachusetts, specifically, pre-admission screening, postpayment review, and prepayment review.

The UMP Review Process Model
Masspro’s UMP model is based on peer review.

At the initial level, nurses review the cases and may

• approve setting and appropriateness of care,

• refer to a peer reviewer for further review or

• deny services based on billing and non-medical regulations.

Nurse reviewers perform the initial review of a case using screening criteria. (Currently, Masspro uses InterQual® screening criteria sets.)

Cases are referred for further medical evaluation to a physician in the same clinical discipline as the care in question in the following situations:

• If the case fails the initial level of review.

• If the nurse believes the case requires additional review.

Physicians use their medical judgment, current standards of care and regulatory requirements to render a decision on a case. Only a physician can deny care or services based on medical appropriateness and setting.

Masspro notifies the provider when a case is denied, and the provider may request a second review by Masspro. Second-level reviews are conducted by a physician of the appropriate specialty.

Pre-admission Screening
Pre-admission screening review is conducted prior to the proposed admission date for all scheduled elective inpatient admissions to an acute inpatient hospital. Massachusetts regulations, specifically 130CMR 450.208(a)(b)(c)(d), govern acute utilization management, including admission screening.

Regulations specify the following:

• The review may be requested by either the admitting hospital or the attending physician’s office.

• All requests must be initiated a minimum of seven days prior to the procedure. A request may be made by fax or telephone.

• The process includes the opportunity for providers to request reconsiderations and a fair hearing of any reconsideration that is denied.

Prepayment and Postpayment Retrospective Reviews
The prepayment review is a retrospective review conducted after the patient has been discharged but before the hospital has received payment of the claim.

The postpayment review is a retrospective review conducted after the patient has been discharged and after the hospital has received payment of the claim.

The reviews are similar in many ways. The similarities are discussed below and the differences are indicated in the table below.

Similarities
These two reviews share the following components. Both

• are comprised of a random selection of cases that meet specific criteria,

• result in identical processing after the review, specifically,

• the issuance of initial letters for all cases with an issue, and

• placement of any case without issues on the “Approved/Excluded” list,

• allow rebilling of denied inpatient claims as outpatient services, and

• provide a 30-day timeframe for appeal to the Board of Hearings after the date of Masspro’s final letter.

Differences
Massachusetts regulations which control these programs, specify certain requirements that result in differences. The table below highlights those differences.

Quality Improvement Projects (QIPs)
QIPs are part of the UMP process. They are focused studies that explore clinical areas of interest or concern to MassHealth. Masspro has expertise in establishing and implementing the development of meaningful QIPs.

QIPs are designed to identify both best practices and opportunities for improvement in the delivery of health care services. With the information obtained from QIPs, Masspro has been able to identify opportunities to improve the quality of health care for MassHealth Members. Currently Masspro is performing an inpatient perinatal care QIP that uses national quality measures and clinical guidelines in the study design. Past QIPs have focused on maternity care, emergency department utilization, discharge planning, and asthma and diabetes care.

Although the scope and duration of a particular QIP is defined by contract, the information from one QIP may result in the development of additional QIPs, illustrating that quality improvement is an ongoing and evolving process.

The scope of Masspro’s efforts in the QIP process may include

• researching medical literature to identify measures appropriate for study,

• analyzing paid claims to identify the sample,

• developing abstraction tools,

• obtaining baseline data regarding clinical practice in one or more facilities,

• performing data abstraction,

• analyzing results,

• convening state-wide meetings to share findings,

• working with providers, and

• performing re-measurement

Masspro strives to ensure the information gathered for QIPs is both accurate and consistent. All nurses must participate in inter-rater reliability (IRR) and must achieve a 95% agreement rate.