HomeMy WebLinkAboutCity of Tamarac Resolution R-86-3081
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*Introduced by; !�/ Temp. Reso. # 4248
CITY OF TAMARAC, FLORIDA
RESOLUTION NO. R-86-,30 8
A RESOLUTION APPROVING AND AUTHORIZING THE
APPROPRIATE CITY OFFICIALS TO EXECUTE AN
AGREEMENT WITH MEDICAL FOUNDATION SERVICES,
INC.; PROVIDING FOR PRE -ADMISSION REVIEW,
CONCURRENT REVIEW, SECOND SURGICAL OPINION
AND HOSPITAL BILL AUDIT IN CONJUNCTION WITH
THE CITY'S SELF -INSURED HEALTH PROGRAM; AND
MVIDING AN EFFECTIVE DAT
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF
TAMARAC, FLORIDA:
,SECTION 1: That the City Council of the City of Tamarac
hereby approves an Agreement between the City of Tamarac and
Medical Foundation Services, Inc. attached hereto and made a
---part hereof as Exhibit "A"•
CT That the appropriate City Officials are
hereby authorized to execute said Agreement.
SECTION 3: This Resolution shall become effective
immediately upon adoption.
PASSED, ADOPTED AND APPROVED this /D day of , 1986.
BERNARD HART
MAYOR
ATTEST:
�MRITT-Ym BERTH F MAYOR HA
CITY CLERK Ir
I HEREBY CERTIFY that I have
approved the form and correct-
ness of this RESOLUTION.
A.t3ANT A GAT
ATTORN Y
20178/7/86--t
RT
DIST. 1: C/W MASSARO
DIST. 2: V/M STELZER
DIST. 3: C/M GOTTESMAN
DIST. 4: C/M STEIN
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r•+ yam.: � ��,; :�;�T�
mwimEps3m, 3M.
3625 N.W. 82ND AVM, # 211
UNU, P RtMe 33166
(305) 593•-0404 ONM
(305) 921-5666 OWO
1-800-621-0002 QUA. T= PRO
Zo I' • `� • CM. D1,V1 ill
THIS AGREE made and entered into as of the 1st day of
October 1, 1986 by and between City of Tamarac, hereinafter
referred to as "Company", and Medical Foundation Services, Inc.,
a private non-profit organization, hereinafter referred to as the
"Review Organization".
WREREAS, the parties to this Agreement agree that utilization
review offers an opportunity to enhance the quality of in -
hospital care while improving the utilization of hospitals; and
WHEREAS, the Review Organization conducts the concurrent evalua-
tiro—' n and review program for the purpose of utilization review;
and
SAS, it is in the best interest of the Company and its
contractors to reduce in -hospital medical costs and improve the
quality of in -hospital medical care for persons covered under the
contractor's health benefit programs and receiving services in
South Florida.
IN CONSIDERATION OF THE M]7UAL,COVENAN7S herein contained, and
for other good and valuable consideration, the parties hereto
agree as follows:
I. The REVIEW CMAMZATION shall:
A. Conduct those review services as specified in Exhibit A.
B. Provide an -appeals mechanism for patient, attending
physician, and hospital if the Review Organization's
determination is questioned.
C. Provide quarterly statistical data and critical
commentary with recommended corrective action within 90
days of the close of the quarter in accordance with
.Exhibit B hereto, to the Company for its information
and comment.
D. Operate a program to analyze in -hospital data oollected
.by the Review Organization related to length of stay and
medical necessity of care and to employ such mechanisms
as are deemed necessary by the Review Organization to
establish appropriate utilization review procedure to
eliminate unnecessary hospital care and to improve the
quality of medical care being rendered to patients by
physicians consistent with applicable confidentiality
requirements.
E. Provide to the Company its case records, staff, -and
professional medical consultation in the event that the
Company is sued or subject to suit for benefits that
have been denied or reduced under circumstances where
the Company's determination is supported by the Review
organization's determination.
A. Consider the Review organization's recommended certification
determination, or any determination resulting from the appeals
mechanism referred to in IB herein, of the medical necessity for
hospital admission or length of stay along with other related
information in arriving at its sole and independent judgment of
the extent of its policy benefit.
B. Reimburse the Fbundation, in accordance with Exhibit C.
C. Notify the Review Organization of each claim that
does not contain the appropriate certification cited in
the Claim Certification Procedure contained in Exhibit A.
D. Notify hospitals by letter on behalf of Review Organization
that Pre Admission Certification and concurrent review is a
requirement for maximum allowable and timely reimbursement.
III. SEWICES/AOSPITUS
A. Services rendered in accordance with this Agreement
shall be limited to employees and dependents designated
by the Company and listed in Exhibit D who are
admitted on or after the effective date of, or during
the period of this Agreement, as in -patients. Exhibit D
may be changed with written notice to the Company
or the Review Organization.
B. Bospitals participating in the Review organization's
review program are listed in Exhibit E. The
.hospitals listed in Exhibit E of this Agreement, may be
changed with written notice to the Company or the Review
Organization.,
A. Term of Agreement. The period of this Agreement shall
extend -from October 1, 1986 until terminated by either
party as provided in C below.
B. The rate of reimbursement may be dhanged from time to
time by written agreement of the parties.
C. Either party may terminate this Agreement with- or
without cause by giving thirty (30) days prior written
notice delivered in person or sent by registered or
certified mail, return receipt requested, proper postage
paid, and properly addressed to the other party at the
address and to the attention of the individual signatory
set forth below, or such more recent address of which
the sending party has received written notice.
D. The Coq=y agrees that the Review Organization shall
be held harmless by the Canpany from all liability
arising out of any negligent acts or failure to act by
Company. Review Organization agrees that Company shall
be held harmless from all liability arising out of any
negligent acts or failure to act by the Review Organiza-
tion.
E. This Agreement may be amended by an addendum signed
by both parties.
F. The thirty (30) day termination period shall
commence as of the date of the postmark of the notice of
termination. During the termination period, the Review
Organization shall omplete those patient reviews in
progress before receipt of the notice of termination,
but shall not commence any new patient reviews after
receipt of such notice of termination. In addition,
Company access to records shall survive any termination.
G. It is understood and agreed that any dispute between
the parties arising under this Agreement shall be
submitted to' binding arbitration. Each party shall
select an arbitrator and the two arbitrators shall
select a third arbitrator.
The arbitration shall be conducted pursuant to the rules
of the American Arbitration Association.
H. The Company and the Review Organization shall set up
compatible procedures to implement and administer this
Agreement. Such procedures shall be shared .with the
other organization to assure procedures are consistent.
I. Choice of Law
It is further understood that in the event of a dispute.
between the parties under this Agreement, Florida law
will apply.
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IN WITNESS FHEREDF, the parties have affixed their hands and
seals the day and year first above written.
CITY OF TAMARAC Medical Foundation Services, Inc.
Cmipany Review Organizatio-n
Address 5811 N W 88th Ave. 3625 N.W. 82nd Ave.c Suite 211
TMIAW, FL. 33321 Miami, Flo da 33166
By
.Z 4
BMMRD HART,NAYOR ive D rec
I HEREBY that I
do have approved the form and
correctness of this docu-
ment.
0
0
Exhibit A
REVIEW SERVICES
Pre Admission Review
Managed Second Surgical Opinion Program
Concurrent review
Billing Audit
M®ICAG MDMTION SERVICES, INC.
`%
PREADV1[SSION r&TM
Introduction
The purpose of preadmission review is to avoid unnecessary admis-
sions, encour outpatient workups and preadmission testing, and
to eliminate�unnecessary preoperative days. The process of pre-
admiss cninrieview is designed to review, prior to admission the
medical necessity of health care services to be provided to
patients treated on an elective inpatient basis.
The Medical Foundation's preadmission review program covers all
non -emergency admissions to acute care and psychiatric hospitals.
Non -emergency admissions must be approved prior to admission.
It is the Medical Foundation's philosophy and practice to perform
all preadmission review screening over the telephone, rather than
by mail. It is our experience that direct verbal interaction is
more effective than having the provider "fill out a form". In
this way, we have an opportunity to pose probing questions that
often bead to reductions in hospital admissions or days of care.
Although our preadmission review determinations are advisory,
they have successfully pEevented hospital expenditures by educa-
ting providers and enoouraging the appropriate use of hospital
services. In 1985, 79 of 1,265 proposed admissions (6.2i) were
diverted to the out -patient setting and 223 pre -operative days
were avoided.
Non-EnergencZr Admission Process
1. The physician planning to hospitalize an employee/dependent
calls the Medical Foundation's preadmission review nurse at
least 24 hours prior to the planned admission. The nurse
asks the physician (or his designee) for clinical information
needed to evaluate the necessity for admission and the anti-
cipated duration of treatment.
2. The preadmission review nurse initiates a preadmission review
certification form that includes patient and physician iden-
tification, anticipated date and place of admission/surgery,
nature of medical conditions warranting hospitalization, and
plan of care.
For elective surgery admissions, the nurse reviewer inquires
about the anticipated length of preoperative stay. Same day
surgery is awhenever it is medically feasible.
Sara preoperative days must be justified by conditions
requiring preparation to improve the patient's operative risk
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status. 41
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Mandatory Ambulatory Surgery: If the admission is for a
surgical procedure that can usually be performed an an out-
patient basis, the nurse reviewer queries the physician to
determine why the procedure cannot be safely performed on an
outpatient basis.
3. The nurse reviewer evaluates clinical information in relation
to admissicn/preoperative criteria. If the criteria are met,
the physician and hospital are notified by telephone (usually
immediately). If criteria are not met, the nurse reviewer
advises the physician's office that the case will be referred
to the Foundation's physician advisor.
4. The nurse reviewer discusses all available information with a
PA. At his discretion, the PA calls the admitting physician
to directly discuss the case. The PA renders an advisory
decision regarding the necessity for admission and/or antici-
pated length of preoperative stay.
S. All pertinent parties are notified of the foundation's
determination. The physician and hospital are usually
notified by telephone before the close'of the working day. If
the admission could not be certified, the patient and the
. employer's claims office are sent a letter of notification
within 24 hours . 'ibis letter includes information about the
process for appealing the advisory decision.
Weekend Admissions
Planned weekend admissions require the same preadmission approval
as weekday admissions. The nurse reviewer gives specific atten-
tion to the need for hospitalization over a weekend and the
availability of anticipated services on Saturday/Sunday.
Psychiatric Admissions
Psychiatric admissions to psychiatric hospitals and to
psychiatric units of acute care hospitals are included in the
Foundation's preadmission review process. Criteria may be
modified by the client.'to reflect their insurance coverage for
psychiatric services.
Materni Admissions
Maternity admissions to a hospital do not require pre admission
certification, however, it is required that the employee or a
family member call the Medical Foundation offices regarding the
admission within one (1) working day of the admission. This will
enable the Medical foundation to monitor the %ngth - of Stay
(UE) throughout the hospitalization.
Emer2na Admission Process
Emergency admissions are exempt from the requirement for
preadmission authorization because the process might delay care
to the patient's detriment. The Medical. Foundation requires that
the Foundation be notified by telephone Within two (2) working
days of emergency admission.
Verification of PreAdmission Review Information
Due bo the heavy reliance during the preadmission review process
on verbal information provided on the telephone, the Medical
Foundation continuously mcnibors all admissions to verify the
information provided by the admitting physician. (See applicable
section of the Ctx=rrent Review Process). This verification
process is necessary to avoid patterns of abuse by providers.
A weekly report is provided bo the employer/insurer that lists
all preadmission review activity from the preceding week. This
report is prepared on Friday afternoons and contains information
pertinent to the carrier's adjudication of the claims (Exhibit
C) .
A monthly Impact Report summarizes the review volume for the
month, number of admissions avoided, and number of preoperative
days saved.
Medical Foundation's Fees
The Medical Foundation charges a fixed monthly rate per employee
covered under the insurance policy.
L1
M®ICAL FOUNDATION SERVICES, INC.
MANAGED SECOND SURGICAL, OPINION PROGRAM
A Managed Second Surgical Opinion Program will assure you and
your employees the medical necessity of elective surgical
procedures without expending unnecessary time and money on
unwarranted Second Surgical Opinions. In many instances a Second
Surgical Opinion is not cost effective. our review program will
'determine which cases warrant a Second Surgical Opinion and which
ones can be eliminated.
This review is available for both in- mtient and out -patient
surgery and can easily be added to our existing Pre Admission
Certification process.
The objectives of our Managed Second Surgical opinion Program are
as follows:
o To identify those instances where indications for
surgery do not meet pre -determined criteria so that
physician peer review can be initiated.
o To avoid unnecessary surgery in those instances where
the attending physician and the physician advisor agree
to an alternative course of treatment.
o To offer the patient an alternative course of action by
encouraging a second surgical opinion prior to the
planned surgery.
o To identify patterns of unnecessary surgery by
procedure, hospital and physician through analysis of
data assembled as a part of the Managed Second
Surgical Opinion Program.
o To avoid unnecessary Second Surgical Opinion fees in
those cases where a Second Surgical Opinion will not be
productive.
Process
When, during the Pre Admission Certification (PAC) process, it is
determined that a surgical procedure is planned for which there
is pre -determined criteria, the PAC nurse will elicit from the
physician the necessary information to determine -if indications
for surgery are met. The PAC nurse wil screen the medical
information received from the physician against pre -determined
surgical criteria. Where criteria are met, no further screening
will be required.
When criteria are not met the PAC nurse will refer the case to a
Physician Advisor who will discuss the indications with the
admitting physician and/or the specialist performing surgery.
MANAGED SECOND SURGICAL OPINION PROGRAM
PAGE 2:
Following the discussion, the Physician Advisor will either
approve the surgery or request that the patient be notified and
encouraged to seek a Second Surgical opinion. If requested, the
patient will be given names of physicians in their area who can
provide this opinion.
The employer and/or insurance Company will be notified by letter
in all instances where a Second Surgical Opinion was recommended.
Reports
Medical Foundation will provide the employer and/or Insurance
Company with a quarterly report indicating the number of such
reviews done and the results of the screening process.
0
MEDICAL FOUNDATION SERVICES, INC.
�J
CONCURRENT REVIEW
Introduction
The purpose of concurrent review is to Eev� unnecessary days
of hospitalization. The necessity for admission and for continued
stay is reviewed against criteria on a cyclical basis. If the
patient does not require (continued) acute care hospitalization,
the Medical Foundation intervenes to facilitate a timely dis-
charge. Although the Foundation's review determinations are
advisory, our experience has been that length of stay for private
insurers has been reduced by one (1.0) day as a direct result of
our review program.
The essence of the Medical Foundation's concurrent review program
is our extensive peer interaction with attending physicians.
Medical Foundation physicians contact attending physicians by
telephone whenever care is questionable. These interactions are
helpful in educating physicians toward more efficient utilization
habits and physicians have generally been responsive to our
review program.
The strength of on -site concurrent review is that it permits
ongoing review of the entire medical record while the patient is
in the hospital. This leads to the best possible decision
regarding the necessity for admission and/ors continued stay. Orr
site concurrent review is also invaluable in verifying
information obtained during the preadmission review process.
On --Site concurrent review services are available at most hospi-
tals in South Florida and in many other hospitals throughout the
State. Off -Site concurrent review is performed when on -site
review is not possible due to small patient volume and/or remote
location.
On -Site Concurrent Review Process
1. The Foundation is notified by the hospital of all insured
admissions within one working day of the admission.
2. The review coordinator (RQ screens all admissions within one
working day of the admission utilizing severity of illness
(SI) and intensity of service (IS) criteria (Exhibit D).
In addition, the RC reviews clinical data pertinent to the
preadmission review process and records the data on the
review form: emergency versus planned admission, patient's
condition at time of admission, and admitting physician's
adherence to treatment plan provided to the preadmission
nurse. This information is recorded on the review forms and
periodically analyzed to verify conpliance with the preadmis-
sion review process.
3. If the medical record meets both SI and IS criteria by the .
third day following admission, the AC approves the admission
and schedules continued stay review to be performed within
the, next three days. If, the medical record does not meet SI
and IS criteria by the third calendar day following admis-
sion, the IC refers the case to a physician advisor (PA) for
further evaluation.
4. The PA reviews the case and attempts to call the attending
physician.for additional information prior to making his
determination. The PA either approves the stay for up to
three additional days or issues a notice of denial (Exhibit
F) indicating that further hospitalization is not medically
necessary.
5. Continued stay review is performed on a cyclic basis (Exhibit
E). Although the timing of each continued stay review is
determined by relevant evidence available from the patient
record, the general rule is that the time between admission
approval, the first continued stay review, and successive
continued stay reviews is not to exceed three calendar days.
6. Continued hospital stay is approved if the case meets IS
criteria. When the record fails to meet IS criteria,
discharge review is performed. If discharge screens are met
but discharge is.not scheduled within the next calendar day,
the case is referred to a PA.
7. If discharge screens are not met, review is scheduled each
successive working day that is available within a maximum of
three calendar days. If discharge screens are not met by the
expiration of three calendar days, the case is referred to a
PA.
8. Only a PA can issue a denial notice (Exhibit F) indicating
hospitalization is not medically necessary. A copy of this
notice is sent to the attending physician, patient, hospital,
and insurer at the time the denial determination is made.
The decision is advisory and the insurer may accept or reject
the recommendation of the physician advisor.
9. A reconsideration of a denial may be requested by the physi-
cian, hospital, or patient (Exhibit G). The Foundation will
conduct the hearing.
10. Upon discharge, the RC stamps the claim prior to submission
to the insurer, to certify that review was done and to
indicate the number of medically necessary days -of care
(Exhibit H).
Patient identification and demographic information is entered
on the Foundation's review form (Exhibit I). These data are
available for data profiling to identify aberrant practice
patterns.
Introduction
The purpose of preadmission review is to avoid unnecessary admis-
sions, encourage outpatient workups and preadmission besting, and
to elinUiate unnecessary preoperative days. The process of pre-
&&Tss oni oertification is designed bo review, prior to admission
the medical necessity of.health care services to be provided to
patients treated on an elective inpatient basis.
The Medical Foundation's preadmission review program covers all
non emergency admissions to acute care and psychiatric hospitals.
Nan -emergency admissions must be approved rf�or to admission.
However, in order to avoid unnecessary mays in emergency
admissions, we only require notification with two (2) working
days after the emergency hospital admission.
It is the Medical Foundation's philosophy and practice to perform
all preadmission certification screening over the telephone,
rather than by mail. It is our experience that direct verbal
interaction is more effective than having the provider "fill out
a form". In this way, we have an opportunity to pose probing
questions that often lead to reductions in hospital admissions or
days of care.
Althaagh our preadmission certification determinations are
advisory, they have successfully prevented hospital expenditures
by educating providers and encouraging appropriate use of
hospital services. In 1985, 79 of 1,265 proposed admissions
(6.2%) were diverted to the outpatient setting and 223 pre-
operative days were avoided.
1. The physician planning to hospitalize an employee/dependent
calls the Medical Fbundation's preadmission review nurse at
least 24 hours prior to the planned admission. The nurse
asks the physician (or his designee) for clinical information
needed bo evaluate the necessity for admission and the anti-
cipated duration of treatment.
2. The preadmission review nurse initiates a preadmission review
certification form that includes patient and physician iden-
tification, anticipated date and place of admission/surgery,
nature of -medical conditions warranting hospitalization, and
plan of care.
For elective surgery admissions, the nurse reviewer inquires
about the anticipated length of preoperative stay. Same day
surgery is encouraged whenever it is radically feasible.
Sara preoperative days must be justified 'by conditions
requiring preparation to improve the patient's operative risk
status.
Mandatory Ambulatory Surgery: If the admission is for a
surgical procedure that can usually be performed on an out-
patient basis, the nurse reviewer queries the physician to
determine why the procedure cannot be safely performed on an
outpatient basis.
3. The nurse reviewer evaluates clinical information in relation
to admission/preoperative criteria and assigns an approved
estimated length of stay (LOS) based on PAS norms. If the
criteria are met, the admission is approved and the physician
and hospital are notified by telephone (usually immediately).
If criteria are not met, the nurse reviewer advises the
physician's office that the case will be referred to the
Foundation's physician advisor (PA).
4. The nurse reviewer discusses all available information with a
PA At his discretion, the PA calls the admitting physician
to directly discuss the case. The PA renders an advisory
decision regarding the necessity for admission and/or antici-
pated length of stay.
5. All pertinent parties are notified by letter of the Founda-
tion's determinations. This letter includes the assigned Los
and information about the process for appealing the advisory
decision. (The physician is usually notified by telephone
before the close of the working day.)
Weekend Admissions
Planned weekend admissions require the same preadmission
approval as weekday admissions. The nurse reviewer gives
specific attention to the need for hospitalization over a
weekend and the availability of anticipated services on
Saturday/Sunday.
Ps2chiatric Admissions
Psychiatric admissions' to psychiatric hospitals and to psychia-
tric units of acute care hospitals are included in the Founds--
tian's preadmission review process.. Criberia- may be -codified by
the client to reflect their insurance coverage for psychiatric
services.
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Emergency Admission Process
Energency admissions are exempt from the .requirement for
preadmission authorization because the process might delay care
to the patient's detriment. The Medical Foundation requires that
we be notified by telephone within two working days of emergency
admission, so that an approved estimated Length of Stay (L)6) can
be assigned. A letter is then sent to all parties informing then
of the initial.tDS and the process to be followed if additional
days are needed.
Maternity Admissions
Maternity admissions to a hospital do not require pre admission
certification, however, it is required that the employee or a
family member call the Medical Foundation offices regarding the
admission within one (1) working day of the admission. This will
enable the Medical Foundation to assign the appropriate LOS in
order to monitor the stay.
Extended Stay Extensions
In those instances where the approved tW is not sufficient to
conclude treatment to a given employee, it is the
physician/hospital's responsibility to call the Medical
Foundation and request additional days. The Pre Admission
Review (PAY) Nurse will evaluate the plan of treatment and the
extension of days against predetermined criteria to determine if
the extension can be approved. If criteria are not met the nurse
reviewer advises the physician that the case will be referred to
a physician advisor (PA).
The nurse reviewer discusses all available information with a PA.
At his discretion, the PA calls the admitting physician to
directly discuss the case. The PA renders an advisory decision
regarding the necessity for continued hospitalization.
All pertinent parties are notified by letter of the Foundation's
determinations. This letter includes information about the
process for appealing the advisory decision.
A meekly report is provided tD the employer/insurer/TPA that
lists all preadmission review activity from the preceding week.
This report contains information pertinent too the carrier's
. adjudication of the claims, including the assigned IM and any
extensions.
M®ICAL FOUNDATION SlEam( a INC.
BILLING AUDITS
Introduction
In 1983, a study by the United States General Accounting Office
(GAO) revealed that 0.4% of hospital charges in a national sample
were for services that were not rendered. More recently, the
Medical Foundation's own billing audits have revealed far higher
error rates at many of Dade and Broward's hospitals. This repre-
sents tens of thousands of dollars in over -payments by employers
and insurers.
It is a well accepted fact that billing audits have the potential
to yield substantial savings. This potential is even greater when
billing audits are incorporated into a comprehensive review
program. Whereas the review coordinator becomes thoroughly
familiar with the patient's treatment during the concurrent re-
view process, the billing audit can be performed with a minimum
of additional effort. This approach is more efficient than
independent audit by a claims administrator or carrier because it
eliminates redundant work.
Billing audit services are available on a prepayment basis in all
hospitals where the Medical Foundation performs on --sine concur-
rent review. Prepayment review, i.e. review prior to submission
of the claim, is advantageous to employers and insurers because
erroneous charges can be corrected before the claim is paid. In
all other hospitals, the'Medical Foundation can arrange to per-
form billing audit services after the claim is submitted.
Billing Audit Process
1. The R^ examines the itemized bill and selects the following
for audit:
a. Claims exceeding $15,000
b. Claims where laboratory, respiratory therapy, or pharmacy
charges constitute a disproportionate amount of the bill
(approximately 25%, or over)
c. Claims for which the dates of service are not consistent
with the dates of hospitalization
.d. Claims discrepant from the RC's concurrent review informa-
tion.
Additional claims may be audited by the RC if unusual items
are detected.
2. Claims that are audited must meet two criteria:
a. Each service must be ordered by a physician, and
b. given, as ordered.
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.
3. The RC marks each erroneous item on a copy -of the bill. if
the review is performed prior to payment (i.e.- at a site
where concurrent review is done), the -RC returns the original
claim to the provider for correction and retains a photocopy
of both the erroneous and, upon receipt, of the corrected
claim. The Medical Foundation utilizes this copy of the
claim to tabulate the financial savings to the
employer/insurer.
4. The the RC stamps the corrected claim: 'Bill Audit Done". If
bill audit was performed after the claim was submitted to the
insurer, the Medical Foundation will forward to the
employer/insurer a statement detailing the billing errors and
amount of overcharges.
Reports and Fees
A monthly report contains a tabulation of erroneous charges for
audited claims. Photocopies of the corresponding claims are
appended to this report. The Medical Foundation bills the
employer/insurer for a fixed percentage of the aggregate
difference between the erroneous and corrected bills.
[J
17J
HOSPITAL REVIEW SUMMARY
MEDICAL FOUNDATION SERVICES, INC.
EXHIBIT B 0
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MEDICAL FOUNDATION SERVICES, INC.
PRE ADMISSION CERTIFICATION (PAC) REPORT
R rt # 1 = Monthly summary:
o Total Calls - total number of calls received by
Medical Foundation. Includes all types of
admissions: elective, maternity, emergency. Does not
include employee questions or counseling calls.
o Prior to Admission - Total number of calls received
prior to patient being admitted to hospital. This
category is split into two kinds of cases:
o Elective - Number of calls relating to an
elective admission, received prior to
admission. This is the only category where
there is potential for review impact, ie.
change to out -patient setting or reduce pre -op
days.
o Non -Elective - Number of calls relating to
maternity admissions. These calls are
informational only and there is W potential
for impact.
o Post Admission Notification - Number of calls
received after admission to hospital. This category
is intended to apply only to emergencies, however,
in many cases we cannot verify the nature of the
admission since we do not yet have documented
information, only the patient's or physician's
stated impression. There is no potential for impact
dB in this category as the admission has already taken
place.
o Within required time period - number of Post
Admission Notification calls received within
the required time period. (usually 48 hours or
2 working days).
q After- required time period - number of Post
Admission Notification calls received after
required time period.
continued...
0
MEDICAL FOUNDATION -SERVICES, INC.
PAC REPORT EXPLANATION
PAGE 2:
Report # 2 - Pre Admission Impact Rates:
Review Activity -
o Cases reviewed by nurse - number of calls actually put
through the Pre Admission Certification (PAC) process.
Limited to Elective admissions called in prior to admis-
sion, ie. where there is potential for impact.
o cases referred to Physician - number of cases where
nurse was not able to approve or resolve and
therefore had to be referred to a Medical Foundation
Physician Advisor (PA).
Impact on Admissions:
Voluntary change to out -patient - number of cases where
hospital admission was avoided as physician agreed to out-
patient setting. (Letter sent to verify)
Admission Denied - number of cases that could not be
approved as medically necessary hospital admissions and
physician or patient would not agree to out -patient setting.
(Letter sent to verify)
Sub -Total - sum of above two categories.
-Impact on Umgth of Stay (LOS) :
Prep days avoided - number of actual pre -op days avoided
by encouring AM admissions. The number of days shown is the
difference between what the physician requested initially
and to which he agreed after review.
0 continued...
MEDICAL F JNDATION SERVICES, INC.
PAC R!�FIORT EXPLANATION
PACE 3:
Estimated Benefit:
5/86
Impact on Admissions - Represents total days of hospital
care avoided due to number of admissions avoided. Fbr each
"avoided" admission we claim a savings of 3 days of hospital
care.
Impact on Length of Stay (LOS) - Total number of pre -op
days avoided.
Sub -Total - Total number of days avoided due to avoided
admissions and prep days saved.
Estimated Benefit - Total number of days saved X $ 400 per
day - projected savings. This cost per day saved is based an
the following:
Cost Per DavSaved
our client's 1985 average cost per hospital day was $ 779:
$ 241 room and board and $ 538 ancillary services. When we
save a day of care for our client, we do not believe it is
realistic to claim that we have "saved" $ 779. Some services
and oosts are not eliminated even though the length of stay
(LOS) is shorter and/or treatment is provided on an out-
patient basis. Pbr this reason, we conservatively attribute
only $ 400 to each day saved. Ibis amount represents the sum
of the average room and board and a fraction of ancillary
charges.
I)MAL.' romm2m SEWIC'FS, iNC.
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MEDICALL FOUNCRTION SERVICES, INC.
HOSPITAL RWIM7n1 AC DESCRIMM OF D0I044
COMM LAMA -1( PTION
(Hasp. #) Hospital Done #
(Total Admits) # of hospital admissions identified and reviewed.
(ALOS) Average Length of Stay (ALM) for all cases reviewed.
(PC Reviews) # of non physician reviews performed by Professional
Coordinator (PC) .
(No. of Referrals The number (#) and percent (S) of times the PC referred a a
& Referral Rate)
case to a Physician Advisor (PA) because she could not
certify continued hospitalization based on pre -determined
criteria. This does not mean the patient did not require
hospitalization -- it only means the case did not meet
standard criteria.
(No. of Contacts
The # and a of times the Physician Advisor could not
& Contact Rate)
certify continued hospitalization based on information in
the medical record. This does not mean the patient did not
•
need hospitalization, it only means the medical record did
not support the need for continued hospitalization and the
Physician Advisor needed ba call the attending physician to
discuss the case in question.
.(No. of Ind.D/Cs
The # and % of times the patient was discharged within
& Ind. D/C Rate)
24 hours due to the Physician Advisor's contact with the
attending physician. These induced discharges represent
over -utilization that was prevented without a formal denial
of benefice.
(No. of Denials
The # and a of times a formal denial is issued because the
Denial Rate)
physician advisor and attending physician could not reach an
agreement about the need for hospitalization. In these
instances, a letter is delivered to the patient, hospital,
physician and eo pay notifying them of our advisory
decision.
(Days
The number of days certified: as medically necessary
Approved)
based on the review system. after a
rnot �irr.].uded
•
denial issued are this statit stic.
F
mays
mays Denied)
Days denied are those days used by a patient after a denial
has been issued and the 24 hour. grace period has passed. The
low # of days in this category supports the appropriateness
of our denials sine physicians and patients usually agree
to a discharge once a denial is issued.
(Total IOS)
low days of care (MC) used by the patients under reviews
Includes medically necessary and medically unnecessary days.
1. Rates
Pre Admission Certification Only
Pre Admission Certification and
Concurrent Review
Concurrent Review Only
Managed Second Surgical Opinion Program
Billing Audits
EXHIBIT C
$ 22.00 per review
$ 46.00 per admission
$ 34.00 per admission
$ 10.00 per review
20% of Savings
2. RNMnt Tlerms
Reimbursement shall be made within a reasonable time after the
Fbundation has submitted an itemized monthly billing statement of .those
insureds for whom the review was performed, but in any event, not later
than thirty (30) days after date of mailing of each such itemized
billing statement.
•I
7�
4b
0
is r
Review will be limited to employees and dependents of group
customers designates] below:
U
0
City of Tamarac
6 MEDICAL FOUNDATION SERVICES, INC,
EXHIBIT E
STATUS REPORT' ON HD6P1Tm PAtrI'ICIPAT m
Provider Listing
Alphabetic by County
Prov.r
vital Review status
1 3
240
DADE COI Nry
ARM BATES LEA M X
008
BAPTIST X
009
CEDARS X
183
CORAL GABLES X
002
CORAL X
020
DO GABLES X
005
BLIRBM VIM (PL DODGE) X
053
HINEM X
004
HIS PARK X
131
HCPRNA. BISCAYNE %
022
JET MGM. X
125
J.A. SKM X
209
KEMALi. TMIONAL (AMER) X
181
UMIN WWAL X
061
HEM X
031
Pffm CHILDMIS X
222
MIA@II GENERAL X
060
MUM How X
034
M3 Nr snw g
]52
Nmtm GABLES (As= X
033
�
NO -MUM MED. CTR. X
029
g
050
PALM SPRINGS g
187
PALM= g
076
PAN AMMtU= g
114
PAMWRY g
IS4
S0um MIAMI X
172
SOUS v g
036
g
059
sr. PpRi IS g
079
iX+ - OF MrAMI Y
100
VICTORIA x
165
g
Key:
1 FUU Oartkipat Lm, aU contracts
3 = Betiae or offWsihe.review
7/86
0
0
STATUS REPORT ON HOSPITAL, PARTICIPATION
Provider Listing
Alphabetic by County
Prov. Hospital Review Status
Number Name 1 2 3 4
BimWARD COUNTY
039
BRIVARD GENERAL
X
042
DOCTORS BROAPM
X
085
DOCTORS GENERAL
X
210
FLA. MED. CENTER
X
000
Fr. LAUDEIMALE
X
.225
HOLLYWOOD NED. CTR.
X
073
HOLY CROSS
X
228
HUMANA BENNEIT
X
199
EttiANA CYPRESS
X
194
HUMANA SO. BROWARD
X
200
IMPERIAL, POINT
x
120
LAS OLAS GENERAL
x
189
N.W. REGIONAL HOSP.
X
038
MENDRIAL
X
056
NORTH BEACH
X
086
NORTH BROWARD
X
237
NORTH RIDGE
X
230
PEMBROKE PINES
X
167
PLANMTION GENERAL
X
224
UNIVERSITY UOMMIN.
X
PALM BEACH
208
168
258
207
144
130
262
234
080
253
176
010
000
269
7/86
x _
x -
X
X
X (Pahokee)
X (Belle Glade)
X
9
Key:
1 - Full participation, all oontrafts
2 - Limited participation for'Selected Clients
3 s Retrospective Review
-4 a Off -Site Concurrent Review