Quality and compliance requirements are equally important. MRIoA must meet client needs and at the same time ensure that both our clients and MRIoA avoid being put at risk due to non-compliance. When audited (by accrediting organizations such as URAQ or NCQA, or at the state or federal level) documentation must demonstrate that guidelines, laws and rules have been followed, and that appropriate processes have been followed. The most exquisite and objective review report, supported by extensive peer-reviewed literature and medical evidence, completed in a timely manner, may be rendered unusable if even one portion of a requirement is not followed. This is not in the best interest of patients, providers, or clients. Knowing the rules and providing valuable information when cases are submitted can help avoid potential incidents.
The online submittal form is a valuable tool for our clients to convey their needs, and for MRIoA to ensure not only that those needs are met, but that all are in compliance. The more information that a client provides to MRIoA using the designated fields on the submittal form, the better we are able to meet their needs, not only in terms of the review specialist, but the level of the review, and compliance with state and accrediting body requirements. Additionally, it will help both MRIoA and you, our clients, to provide accurate reporting to regulatory bodies. Much of the information included in the designated fields of the MRIoA submittal form can be tracked in our system, allowing for more robust reporting capabilities. Not including some of the information could result in delay of the case, clarifications and/or complaints due to our analysts having to reach out to the client to clarify or obtain necessary information.
Help us by accurately indicating the Case Level (Initial, Reconsideration, 1st Appeal, 2nd Appeal, Federal IRO, State IRO). This will allow MRIoA to help you by ensuring the appropriate URAC, NCQA, state, and federal requirements are met, such as specialty match, turn-around time, etc.
Help us by accurately indicating the plan type (fully-insured, self-funded) and plan state on each and every case. This is important because MRIoA must follow different sets of requirements for fully-insured and self-funded cases, and it will allow MRIoA to help you provide accurate reporting to accrediting and regulatory bodies.
Help us and avoid confusion by knowing the state guidelines for the fully insured cases you submit to MRIoA. We will help you by advising that this information is available to you in the Resources section on the ClientTools website for your reference.
Example 1 – Texas requires that URAs afford the treating provider a reasonable opportunity to discuss the case prior to issuing an adverse determination. “Reasonable opportunity” is defined as follows:
“At least one documented good faith attempt to contact the provider of record that provides an opportunity for the provider of record to discuss the services under review with the URA during normal business hours prior to issuing a prospective, concurrent, or retrospective utilization review adverse determination:
(A) no less than one working day prior to issuing a prospective utilization review adverse determination;
(B) no less than five working days prior to issuing a retrospective utilization review adverse determination; or
(C) prior to issuing a concurrent or post-stabilization review adverse determination.” 28 TAC § 19.1703
Translation: If a case is submitted with a requested 24 hour turn-around time, MRIoA might be unable to comply with both the state requirement and the client’s requested turn-around time unless the reviewer is able to approve without a peer-to-peer. For example, if a fully-insured Texas prospective case is submitted to MRIoA at 3 pm Mountain Time, it is likely that the reviewer will not be able to make a peer to peer attempt during the treating provider’s business hours until the morning of the next business day, and subsequently may need to wait the full duration of the required time frame as described above (one business day for prospective; five business days for retrospective) before rendering an adverse determination.
Example 2 – The appeal process in Massachusetts differs slightly from many other states. Massachusetts considers a “reconsideration” to be an appeal requested by the treating provider versus a “grievance”, which is an appeal requested by the insured. Massachusetts requires reconsiderations to be conducted between the treating provider and a Massachusetts licensed reviewer within one working day of receipt of the request. It is not always possible for contact and a discussion between the reviewer and treating provider to occur due to the limited time allowed by state mandate. In these instances, the reviewer will document that an attempt to reach the treating provider was made and complete the review. MRIoA is not able to delay or extend the case for additional call attempts, as doing so will result in noncompliance with the state requirements.
Being aware of the requirements of the various accrediting bodies and states and how they differ from case to case will provide a clear understanding, allow you to plan internal processes to avoid potential delays required to ensure compliance, and keep you from being at risk due to non-compliance. It will also improve the quality process by reducing the number of clarifications and complaints resulting from unfamiliarity with the requirements.
Valerie Surber, Director of Quality Management
Aja Ogzewalla, Director of Regulatory Compliance
