Acute Review
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.
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.
Masspro’s UMP model is based on peer review.
At the initial level, registered nurses review the cases and may
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approve setting and appropriateness of care,
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refer to a peer reviewer for further review or
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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 may be referred for further medical evaluation to a board certified, actively practicing physician in the same clinical discipline as the care in question. 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 review is conducted prior to the proposed admission date for all scheduled elective inpatient admissions to an acute inpatient hospital. Massachusetts regulations, specifically 130 CMR 450.208, govern acute utilization management, including admission screening. Admission and concurrent screenings are performed on all admissions and continued stays in the MassHealth acute rehabilitation units located within acute hospitals. These reviews are governed by Massachusetts regulations 130 CMR 435.408-412.
Regulations specify the following:
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The review may be requested by either the admitting hospital or the attending physician’s office.
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All requests must be initiated a minimum of seven days prior to the procedure. A request may be made through NewMMIS or by fax or telephone.
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The process includes the opportunity for providers to request reconsiderations and a fair hearing of any reconsideration that is denied.
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.
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