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Q -- REQUEST FOR INFORMATION -- DRAFT 6TH STATEMENT OF WORK (SOW) FOR PEER REVIEW ORGANIZATIONS (PROS) DUE 111698 POC Brenna Smothers, Contract Specialist, 410-786-1277 Edward Hughes, Contracting Officer, 410-786-0203 A draft of the Peer Review Organization (PRO) 6th Statement of Work (SOW) is being made available for review and comment. The Payment Error Prevention Program (PEPP) is born out of two concerns. First, there is an intolerably high amount of money spent in error in the Medicare program and, second, it is the responsibility of the Health Care Financing Administration (HCFA), as the program manager, to deal with this problem. Most errors are not fraud, most errors are human beings attempting to use and manage a complex process to accomplish a social good. For Medicare, this social good is providing health care to the nation's elderly population. Monitoring for these errors and minimizing their occurrence is the purpose of PEPP. In particular, PEPP is directed to inpatient Perspective Payment System (PPS) services and includes correct coding as well as the provision of necessary services. The PROs will be required to develop projects to monitor the suitability and accuracy of payments for services providedto Medicare beneficiaries. They will also be required to develop programs to educate provider and practitioners on how to prevent these errors, to correct the effects of previous errors and to monitor the effects of their intervention efforts. Fraud in the Medicare system is an intentional misrepresentation to obtain payment, but payment for fraudulent bills is also an error to be prevented. Detecting and prosecuting fraud, abuse and waste is the responsibility of special contractors and law enforcement agencies. However, the PROs are required to conduct such analyses as necessary to find mistakes, determine the nature of the mistakes and take appropriate actions. If these mistakes are persistent, intentional misrepresentation of facts or otherwise determined to represent consistent attempts to inappropriately enhance reimbursement, then the PROs will have mechanisms in place to draw in the fiscal intermediaries to engage in overpayment recoveries and the Office of the Inspector General to investigate and prosecute as appropriate. The draft contains a new Task outlining the PROs responsibilities with regard to Quality Improvement System for Managed Care (QISMC). The PRO will not be responsible for determining whether a particular Managed Care Organization (MCO) meets QISMC standards. More specific directives on the QISMC activities of PROs (which are scheduled to begin January 1, 1999) will be issued shortly by HCFA's Office of Clinical Standards and Quality. The indicators for the National Health Improvement Topics were chosen in an effort to balance the importance and relevance of the indicators with the likelihood of being able to effect and measure improvement. Many, such as those selected for Acute Myocardial Infarction, Stroke, Congestive Health Failure and pneumonia treatment, have been used in successful inpatient projects. The diabetes measures are those measures from the Diabetes Quality Improvement Project which were amenable to measurement using administrative data. Influenza and pneumococcal vaccination and mammography are well-supported preventive practices. HCFA is acutely aware of the need to ensure that the quality indicators remain sound throughout the entire contract period. To this end, we expect each Clinical Area Team (CAT), working in conjunction with its respective Clinical Area Support PRO (CASPRO) to: 1) Keep abreast of current developments, 2) Participate in and rely on expert panels and resources in professional associations, governmental agencies (i.e. AHCPR, CDC, NIH) and consumer representatives, 3) Make appropriate modifications to the indicators and the evaluation scheme, when necessary, and 4) Develop methods to measure increasingly relevant indicators in more appropriate settings. To evaulate the PROs work under the national projects task we intend to create a combined weighted average of the entire set of quality indicators. By evaluating the PROs based on this global measure, we give the PROs the latitude to determine how best to distribute their improvement efforts so that they achieve the maximum feasible improvement, taking into account local conditions. The combined weighted average will be calculated in two steps. The score for each clinical priority will be a weighted average of the indicators for that priority. The weights will probably reflect an estimate of both the clinical impact and the feasibly achievable improvement in each indicator. We are still working on the detail of this weighting scheme. As a second step, the six clinical topic weighted averages will be combined, with equal weights, into an overall average. After a great deal of internal and external discussion and consultation, we believe the following percentages roughly represent the relative level of effort: 1) 60% -- QIP (75% -- National, 25% -- Local) 2) 30% -- PEP 3) 10% Beneficiary Rights/Outreach/Statutorily Mandated Review Activities We anticipate the Standard Data Processing System will be modified to allow most, if not all of the QIP and PEPP activities to be reported through systematic, regular, routine data entry and that PROs should not have to spend time and effort creating and submitting a great many ad hoc reports. Further information including specific directives on this activity should be available at the time the Request for Proposal (RFP) is published and will be included with that document. At this time, we are seeking comments on the overall direction of the PRO program as documented in the draft 6th SOW. The specific processes will be described in the PRO Manual sections which will be part of the RFP now scheduled for publication in early January. Comments received will be taken into consideration when finalizing the SOW but will not be responded upon individually. If you would like your comments to be considered, they must be submitted no later than November 16, 1998 to: Ms. Susan Smith via E-Mail (SSmith1@hcfa.gov), fax (410-786-8532) or mail (Ms. Susan Smith, Health Care Financing Administration, Office of Clinical Standards and Quality, Mail Stop S3-02-01, 7500 Security Boulevard, Baltimore, MD 21244-1850). These points of contact are for comments ONLY, the SOW can be viewed as noted below. You may view the SOW at the following website address: http://www.hcfa.gov/quality/qlty-5b.htm. If you require a hard copy of the SOW, you may contact Brenna Smothers at 410-786-1277 and one will be mailed to you. Posted 11/02/98 (I-SN267385). (0306)

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