Need Help: Quality review vs normal managerial/director responsibilities.

[ArtMR13]

Thank you in advance for any clarification you can offer.

Our firm was retained to staff for a Quality Review Director in Behavioral Health. The recruiter offering the assignment has been unable to provide much clarification with respect to the position.

The requirements are essentially someone who act in the following capacity:

"Oversees all aspects of department QR processes including policy and procedure development and monitoring, outcomes management, monitoring/tracking, incident report analysis, managed care credentialing, accreditation/licensing monitoring, etc. Involved in evidence based practice development for Behavioral Health."

My question is the following. The position doesn't appear to be standard for most behavioral health departments. In the absence of a specific employee in charge of "quality review" to oversee those functions, whom generally in the behavioral health department would act in that capacity? For example would it be the Director who would perform those duties?

[aloevera]

It sounds like our QA in our hospital....Quality Assurance....An RN is in this position....

[RNdaze]

Everybody needs a Compliance/Integrity Officer!

AKA: Incidence analysis slooth. Policy and procedure overlord. Persistantly caught between a rock and a hard place middle-man.

Director's are tired of the heat? Behavioral must make sure I's are dotted and T's are crossed so the hospital can be properly reimbursed and is billing for services that are rendered and necessary. For Behavioral, this seems to be monumental task.

From what our Integrity/Compliance Officer has said, he's not a real popular guy. :chuckle He ought to have "If you didn't chart it, it didn't happen" tatooed across his head. He said Behavioral Health is the latest to have a big red target painted on it's rear by the gov'mnt. Hellooooooo Medicare! New positions available!

Here are a couple similiar job descriptions I found on a quick google, not specific to Behavioral Health, but a tad more descriptive:

- Plans, organizes and directs a quality assurance program within a State general hospital; sets up operating units for prospective review, concurrent review and retrospective review functions relating to admission request, pre-admission clinical testing, admission necessity certification, length of stay review, discharge planning, evaluation of utilization review, continuing criteria development and education.

- Renders decisions on unusual problems that involve policy interpretations or consults with medical staffs and hospital direct for advice on problems requiring medical and/or procedural knowledge.

- Continuously evaluates procedures to provide more efficient methods; revises reporting forms to provide for more complete and condensed data; consults with proper committees in the distribution and filing of information.

- Establishes safeguards to preserve the confidentiality of information from the patient medical records or other sources of patient information, assists authorized personnel in the implementation and use of quality assurance data and reports.

- Consults with the medical staff and hospital administrators on revisions of reports, seeks cooperation of medical staff in recording and completing medical records of patients to adequately document data necessary for quality assurance evaluations.

- Reviews the data on a non-routine basis, contacts attending physicians or refers to physician reviewer when necessary; assists authorized non-hospital organizations such as Federal, State, professional regulating groups and third-party payers in determining hospital compliance with their respective regulations and standards.

Coordinates at the administrative level with admissions, credit offices, medical records department, social services, and professionals including physicians, nurses, dietitians and therapists in the interchange of necessary information in carrying out the quality assurance program.

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Distinguishing Features of the Work

Assists in planning, organizing, and directing the Quality Assurance Program of which the two main components are Medical Audit and Utilization Review within a State general hospital.

The work includes responsibility for supervision of the utilization review activity conducted on the units, assuring standardization of procedures to be followed in the abstracting and recording of data, assists in developing and coordinating efforts of professional committees toward development and revision of patient care audit and utilization review criteria.

Other responsibilities include teaching computer terminal operation and maintenance necessary to complete utilization review functions. Decisions as to program administration are made in accordance with the Director. This person is immediately responsible to the Director of the Quality Assurance Program.

Examples of duties characteristic of positions in this class:

1. Assist the Director in managing, planning, and organizing the Quality Assurance Program within a State general hospital for the purpose of accomplishing goals and objective for both medical audit and utilization review.

2. Reviews utilization review data on a routine basis and designs reports from existing data to obtain statistics or verify certified action. Ex: would include evaluation of diagnosis, types of services, rendered, why certain test on patients are delayed.

3. Implements an employee evaluation procedure based on the Management by Objectives Program.

4. Coordinates orientation for all new employees by training new employees, writes outline for orientation, selection of team leaders.

5. Renders decisions on utilization of computerized reports and problems involving maintenance and operation of terminal.

6. Conducts staff meetings on weekly basis for the purpose of upgrading skills

.

7. Continuously evaluates utilization review procedures to provide more effective and efficient methods of carrying out the function.

8. Coordinates responsibilities of team leaders and conducts weekly meetings for the purposeof insuring standardization of utilization review procedures.

9. Supervises themaintenance and updating of files on review data and statistics on the efficiency of the utilization review system. Ex: would include monthly reports on admission diagnosis, financial classification, profile on attending physicians, etc.

10. Makes recommendations to the Director based on experience in implementation of the utilization review process.

11. Coordinates in-service programs based on identified needs.

All comes down to the $$$$.

And if you don't do your job, yikes!!!

The Victoria Behavioral Health Services, a Community Mental Health Center located in Miami, Florida, received reimbursement for partial hospitalization services provided to Medicare beneficiaries. The audit showed that the center did not meet the certification requirements established under Sections 1916©94) of the Public Health Service Act and 1861 of the Social Security Act. Further, we found that none of the 20 medicare beneficiaries in our sample were eligible for partial hospitalization benefits and that $1,196,664 of the $1,959,296 paid for services provided to the 20 beneficiaries in our sample were unnecessary, unreasonable and unallowable under Medicare coverage and reimbursement criteria. We also found that the center claimed reimbursement for unreasonable and unallowable administrative costs, including related party costs that had not been properly disclosed.

Based on the audit, we recommended that the entire $4,510,161 paid to the center during their participation in the Medicare program be disallowed. Medicare payments to the center were suspended with notice and the findings were referred for possible criminal prosecution.

Did I digress? oops, sorry bout that. Good luck.