Medical Quality Review Activities

1
Medical Quality ReviewActivities

• Blaise Gerstenlauer
• Manager, Health Care Quality Review

2

• Agenda
• Organizational Structure
• Statutory Language
• Quality of Care Complaints
• Random Reviews
• Medical Quality Review Plan
• Medical Quality Review Panel (MQRP) Quality
  Assurance Panel (QAP) processes
• Designated Doctor Applications

3
Organizational Structure
4

• Office of the Medical Advisor (OMA)
• Medical Advisor
• Howard Smith, MD, JD
• Assistant Medical Advisor
• Ken Ford, MD
• Associate Medical Advisors
• Charlotte Smith, MD
• Clark Watts, MD, JD
• Bill DeFoyd, DC

5

• Health Care Quality Review (HCQR)
• Executive Deputy Commissioner of Health Care
  Management
• Matthew Zurek
• Director of Health Care Business Management
• Mary Landrum
• Manager
• Blaise Gerstenlauer

6
Statutory Language
7

• Labor Code 413.0511
• Medical Advisor
• The medical advisor shall make recommendations
  regarding the adoption of rules and policies to
• Guidelines
• Compliance of guidelines
• Work with MQRP
• Reimbursement methodology
• Decisions issued by DDs, IROs,

8

• Labor Code 413.0512
• Medical Quality Review Panel
• assist the medical advisor in performing the
  duties required under Section 413.0511.  
• shall recommend to the medical advisor
• appropriate action regarding HCPs, ICs, URAs, and
  IROs
• addition or deletion of doctors from the
  designated doctors

9
Quality of Care Complaints
10

• Quality of Care Complaints
• Complaints regarding quality of care
• Health Care Providers
• Designated Doctors
• Complaints regarding medical decision making
• Insurance Carriers
• Peer Review doctors
• Utilization Review agents
• Independent Review Organizations

11

• Complaints are received via
• Mail
• Directly to OMA or from System Monitoring
  Oversight
• Referral from another program area.

12

• Complaint Process
• Entered in Complaint Inquiry System for tracking
  purposes
• Assigned document identification number
• Reviewed by Assistant Medical Advisor
• May be reviewed by MQRP
• May be reviewed by QAP
• May be referred to enforcement

13
Random Reviews
14

• Reviews are based from
• Medical Quality Review Plan
• Monitoring Reports
• Complaint based

15

• Review Process
• Random selection made
• Typically seven cases per review
• Reviews are sent to a MQRP member
• Reviews may be sent to QAP
• Informal Review Conferences may be held
• Reviews may be sent to enforcement

16
Medical Quality Review Plan
17

• Medical Quality Review Plan
• Each year, the TDI-DWC selects categories for
  review
• Based on recommendations from the medical
  advisor, the TDI Workers Compensation Research
  and Evaluation Group, and complaint trends.

18

• Medical Quality Review Plan
• Categories under review may include, but are not
  limited to
• Prompt access to health care
• Accurate diagnosis and testing
• Evidence-based medical treatment
• Reasonable cost
• Appropriate return-to-work outcomes

19

• Medical Quality Review Plan
• Posted on our internet
• http//www.tdi.state.tx.us/wc/hcprovider/medadviso
  r.html

20
MQRP/QAP process
21
(No Transcript)
22

• Conflict of Interest
• MQRP and QAP members with a conflict of interest
  and/or reasonable appearance of a conflict of
  interest with the selected system participant may
  not participate in the related review process.

23

• Confidentiality and Non-Disclosure
• Any information collected, assembled, or
  maintained by the Division regarding a medical
  quality review constitutes a confidential
  investigation file.

24

• Communication
• MQRP and QAP members shall not communicate with
  system participants or any other parties involved
  in the case under review. Members shall not
  communicate outside the groups. No other
  information relating to the review shall be
  disclosed prior to the review of a final report.

25
Designated Doctor Applications
26

• Designated Doctor List
• Steps for becoming a Designated Doctor or an
  Impairment Rating Doctor
• Attend a designated doctor and impairment rating
  course approved by TDI-DWC.
• Pass an impairment rating test approved by
  TDI-DWC.
• Submit an online application through TXCOMP
  http//www.tdi.state.tx.us/wc/txcomp/help/txcomp-
  online.html

27

• Designated Doctor List
• We work closely with the DD scheduling office in
  situations where a DD has
• failed to adequately respond to an LOC
• failed to properly adhere to the standard of care
  (SOC) and
• a re-designation may be necessary

28

• OMA/HCQR Resources
• Dr. Howard Smith, Medical Advisor 512-804-4409
• Blaise Gerstenlauer 512-804-4418
• Mary Landrum 512-804-4814
• Michael Torres 512-804-4766
• OMAs website http//www.tdi.state.tx.us/wc/hcpr
  ovider/medadvisor.html
• DDs website http//www.tdi.state.tx.us/wc/hcpro
  vider/dd.html

29
(No Transcript)