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AHQA Conference Beneficiary Protection and 9 th SOW Update

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AHQA Conference Beneficiary Protection and 9 th SOW Update

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    1. 1 AHQA Conference Beneficiary Protection and 9th SOW Update Jean Moody-Williams, RN, MPP, Director Quality Improvement Group Office of Clinical Standards and Quality February 26, 2009

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    3. 3 VISION To lead a national beneficiary initiated quality of care concern process that improves healthcare outcomes.

    4. 4 MISSION To ensure beneficiary protection through a national standardized process that is accessible, transparent, responsive, consistent, efficient, data driven, and promote quality of care.

    5. 5 So how are we doing in the 9th SOW ?

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    7. 7 6.1 Beneficiary Protection Performance Measures

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    9. 9

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    11. 11 9th SOW Standardization Quality of Care Complaint Form Office for Civil Rights Beneficiary Protection Bridge Contract For all Beneficiary Protection Program functions, there is a need for increased standardization amongst the QIOs. There is significant variation in the way QIOs complete the same reviews and the obligations placed on beneficiaries as well as on physicians and providers differ amongst the QIOs. These differences translate to an inability to precisely account for costs. In addition, we need to improve awareness of all the QIOs’ roles related to the Beneficiary Protection Theme so that beneficiaries, providers and physicians better utilize the QIOs as a resource. As you know, we have developed a standard Medicare Quality of Care Complaint Form. The form will: 1. enable us to simplify the way beneficiaries file written complaints, 2. standardize the manner in which complaints are received by all QIOs, 3. standardize the information QIOs receive related to complaints, including health disparities information, and 4. lay a foundation for future automation efforts for receiving complaints. In addition, we have established guidelines for the Office for Civil Rights (DHHS) to follow in referring potential quality of care complaints to QIOs that we hope will facilitate the receipt of referrals in a more timely manner. In addition, during the period 2/1/2009 through 4/30.2009, TMF will serve as the QIOSC and part of their work will be to review all TOPs and SDPS memoranda as well as QUEST questions and answers to identify which ones need to be incorporated into the manual, specifically chapters 4, 5, 7, and 9. For all Beneficiary Protection Program functions, there is a need for increased standardization amongst the QIOs. There is significant variation in the way QIOs complete the same reviews and the obligations placed on beneficiaries as well as on physicians and providers differ amongst the QIOs. These differences translate to an inability to precisely account for costs. In addition, we need to improve awareness of all the QIOs’ roles related to the Beneficiary Protection Theme so that beneficiaries, providers and physicians better utilize the QIOs as a resource. As you know, we have developed a standard Medicare Quality of Care Complaint Form. The form will: 1. enable us to simplify the way beneficiaries file written complaints, 2. standardize the manner in which complaints are received by all QIOs, 3. standardize the information QIOs receive related to complaints, including health disparities information, and 4. lay a foundation for future automation efforts for receiving complaints. In addition, we have established guidelines for the Office for Civil Rights (DHHS) to follow in referring potential quality of care complaints to QIOs that we hope will facilitate the receipt of referrals in a more timely manner. In addition, during the period 2/1/2009 through 4/30.2009, TMF will serve as the QIOSC and part of their work will be to review all TOPs and SDPS memoranda as well as QUEST questions and answers to identify which ones need to be incorporated into the manual, specifically chapters 4, 5, 7, and 9.

    12. 12 QIO Manual Team Chapters 4, 5, 7 and 9 6 Groups Memoranda and QUEST April 30, 2009 We are also working towards revising chapters 4, 5, 7, and 9 so that QIOs, Project Officers, and other staff have a solid foundation to work from regarding all Beneficiary Protection Theme functions. The work associated with the four chapters has been split up into 6 groups and our goal is to ensure QIOs have a clear avenue through which they can provide input into the revisions, with a focus on maintaining consistent terminology and well-defined processes. As part of this, TMF, the QIOSC, will be assisting each of the 6 groups by identifying SDPS and TOPs memoranda as well as QUEST questions and answers impacting the work of each of the groups so that the groups can incorporate the relevant policy and these memos and questions and answers can be annualized. As a first step, our goal is for each of the six groups to identify the major issues to be addressed by April 30, 2009. As you know, the most significant work related to this initiative has been on Chapter 5, the Beneficiary Complaint chapter. We are also working towards revising chapters 4, 5, 7, and 9 so that QIOs, Project Officers, and other staff have a solid foundation to work from regarding all Beneficiary Protection Theme functions. The work associated with the four chapters has been split up into 6 groups and our goal is to ensure QIOs have a clear avenue through which they can provide input into the revisions, with a focus on maintaining consistent terminology and well-defined processes. As part of this, TMF, the QIOSC, will be assisting each of the 6 groups by identifying SDPS and TOPs memoranda as well as QUEST questions and answers impacting the work of each of the groups so that the groups can incorporate the relevant policy and these memos and questions and answers can be annualized. As a first step, our goal is for each of the six groups to identify the major issues to be addressed by April 30, 2009. As you know, the most significant work related to this initiative has been on Chapter 5, the Beneficiary Complaint chapter.

    13. 13 What Can We Do Better? We are also working towards revising chapters 4, 5, 7, and 9 so that QIOs, Project Officers, and other staff have a solid foundation to work from regarding all Beneficiary Protection Theme functions. The work associated with the four chapters has been split up into 6 groups and our goal is to ensure QIOs have a clear avenue through which they can provide input into the revisions, with a focus on maintaining consistent terminology and well-defined processes. As part of this, TMF, the QIOSC, will be assisting each of the 6 groups by identifying SDPS and TOPs memoranda as well as QUEST questions and answers impacting the work of each of the groups so that the groups can incorporate the relevant policy and these memos and questions and answers can be annualized. As a first step, our goal is for each of the six groups to identify the major issues to be addressed by April 30, 2009. As you know, the most significant work related to this initiative has been on Chapter 5, the Beneficiary Complaint chapter. We are also working towards revising chapters 4, 5, 7, and 9 so that QIOs, Project Officers, and other staff have a solid foundation to work from regarding all Beneficiary Protection Theme functions. The work associated with the four chapters has been split up into 6 groups and our goal is to ensure QIOs have a clear avenue through which they can provide input into the revisions, with a focus on maintaining consistent terminology and well-defined processes. As part of this, TMF, the QIOSC, will be assisting each of the 6 groups by identifying SDPS and TOPs memoranda as well as QUEST questions and answers impacting the work of each of the groups so that the groups can incorporate the relevant policy and these memos and questions and answers can be annualized. As a first step, our goal is for each of the six groups to identify the major issues to be addressed by April 30, 2009. As you know, the most significant work related to this initiative has been on Chapter 5, the Beneficiary Complaint chapter.

    14. 14 Beneficiary Protection Redesign Recommendations from: Beneficiary Input Institute of Medicine Senate Finance Committee Office of Inspector General Government Accountability Office Independent contractor findings (MITRE) CMS internal assessments

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    16. 16 Short-term Goals: November 2008 – December 31, 2009 Develop a proposed Redesign for the Beneficiary Complaint Process Across CMS Explore standardization of various types of case review processes Link case review to quality outcomes Develop proposed performance metrics for 10th SoW Improve methodology for identifying and reducing healthcare disparities

    17. 17 Long-term Goals: January 2010 – January 1, 2011 Improve transparency in case review Redesign the Case Review Information System (CRIS) Identify and address barriers to program monitoring and oversight Explore ideas for Pilots and Demonstrations to test new processes, methods, and systems

    18. 18 Redesign Work Teams Purpose: To plan, develop, and implement approved plans, strategies and processes to redesign the Beneficiary Protection Program. Seven work groups Beneficiary Complaint Process Case Review Methodologies CRIS Redesign Performance Measures Financial/Budget Considerations 10th SOW QIO Manual Updates

    19. 19 Working together, we can make a difference! Discussion

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