Policy/Procedure Number: MPUP3026 (previously UP100326) / Lead Department: Health Services
Policy/Procedure Title: Inter-Rater Reliability Policy / ☒External Policy
☐ Internal Policy
Original Date: 02/16/2000 / Next Review Date: 08/08/2019
Last Review Date: 08/08/2018
Applies to: / ☒ Medi-Cal / ☐ Employees
Policy/Procedure Number: MPUP3026 (previouslyUP100326) / Lead Department: Health Services
Policy/Procedure Title:Inter-Rater Reliability Policy / ☒External Policy
☐Internal Policy
Original Date: 02/16/2000 / Next Review Date:08/08/2019
Last Review Date:08/08/2018
Applies to: / ☒Medi-Cal / ☐ Employees
Reviewing Entities: / ☒ IQI / ☐ P & T / ☒ QUAC
☐OPerations / ☐Executive / ☐Compliance / ☐Department
Approving Entities: / ☐BOARD / ☐COMPLIANCE / ☐FINANCE / ☒ PAC
☐ CEO / ☐COO / ☐Credentialing / ☐ DEPT. DIRECTOR/OFFICER
Approval Signature: Robert Moore, MD, MPH, MBA / Approval Date:08/08/2018
  1. RELATED POLICIES:
  2. MCUP3041 - TAR Review Process
  3. MCRO4018 - Pharmacy TAR Procedure
  1. IMPACTED DEPTS:
  2. Health Services
  3. Claims
  4. Member Services
  1. DEFINITIONS:

IRR: Inter-Rater Reliability

  1. ATTACHMENTS:
  2. Inter-Rater Reliability Study TAR Audit Report –Nurse Coordinator Review
  3. Inter-Rater Reliability Audit Reporting Form – Physician Review
  4. Inter-Rater Reliability Form – Pharmacy Department
  1. PURPOSE:
  1. POLICY / PROCEDURE:
  2. Goal
  3. To ensure that medical management criteria are being utilized appropriately and consistently in UM decision making.
  4. Nurse Coordinator Review
  5. Method of Data Collection
  6. Retrospective review of TARs for services reviewed by Health Services Nurse Coordinators
  7. Staff Responsible
  8. Health Services Project Coordinator
  9. Sample
  10. Inpatient Service
  11. Outpatient Services
  12. Time Frame
  13. An audit summary is reported biannually at the Internal Quality Improvement (IQI) meetingsin March and September.
  14. Results
  15. An accuracy rate of 90% is targeted. Resultsare compiled and presented to the Quality/Utilization Advisory Committee (Q/UAC) for review and discussion. If a nurse coordinator falls below this threshold, a corrective action plan is initiated by the Health Services Department under the direction of the UM Director. The corrective action plan may include, but not be limited to, educational activities, increased review of decisions, and/or institution of staff probationary period combined with supervision of decisions.
  16. Physician Review:
  17. Method of Data Collection
  18. Retrospective review of TARs for services denied by a Physician Reviewer
  19. Staff Responsible
  20. Health Services Project Coordinator
  21. Chief Medical Officer (CMO), Associate and Regional Medical Directors
  22. Sample:
  23. The Health Services Project Coordinator will coordinate and schedule a biannual auditreview of TARs for services denied by a Physician Reviewer. Samples are pulled from three categories. The Health Services Project Coordinator randomly selects10cases ofinitiallydeniedservicesand 5 upheld appeals while the Pharmacy Administrative Assistant randomly selects 10 cases of initially denied pharmacy services fromeach physician reviewer who issued a denial determination in the previous 6 months. Sample TARs selected are audited by a physician not involved in the initial review. The Chief Medical Officer reviews the audit findings.
  24. Over the course of a year period, a sample size of at least fifty (50) cases or 5% (whichever is less) of services denied(for a combination of UM TARS, Pharmacy TARS and Appeals) will be audited for each Physician Reviewer.
  25. If there is no alternate physician available to perform an inter-rater reliability audit, a physician experienced in UM employed by a Medi-Cal Managed Care Plan performs the review.
  26. Time Frame
  27. The audit compliance summary for PHC Physicians is reported biannually at the Internal Quality Improvement (IQI) meetings in March and September.
  28. Results:
  29. An accuracy rate of 90% is targeted. If a Physician Reviewer falls below the 90% threshold, a corrective action plan is initiated by the CMO. Corrective action plans could include but arenotlimited to educational activities, supervision of decisions, increased oversight of UM decisions, or prohibiting the physician from making UM decisions.
  30. PharmacistReview:
  31. Method of Data Collection
  32. Retrospective review of TARs for services reviewed by Pharmacy Reviewers.
  33. Staff Responsible
  34. Pharmacy Administrative Assistant
  35. Sample
  36. The Pharmacy Administrative Assistant (AA) coordinates and schedules the auditing for each year. The AA randomly selects TARs of both approved anddenied cases each quarter.
  37. Over the course of a year period, each reviewer will have a resulting sample size of at least fifty(50) TARs (comprised of approved and denied files) or 5% (whichever is less) reviewed. A pharmacist reviewer performs the inter-rater reliability audit reviewing determinations rendered by another pharmacy reviewer.
  38. Time Frame
  39. An audit summary is reported biannually at the Internal Quality Improvement (IQI) meetings in March and September.
  40. Results
  41. An accuracy rate of 90% is targeted. When compiled, results are presented to the Quality/Utilization Advisory Committee (Q/UAC) for review and discussion.If a pharmacy reviewer falls below this threshold, a corrective action plan is required. Corrective action plans may include, but are not limited to, educational activities, increased supervision of decisions, and/or institution of a probationary period combined with supervision of decisions.
  1. REFERENCES:
  2. State regulatory requirements
  3. National Committee for Quality Assurance (NCQA) Guidelines(Effective July 1, 2018) UM 2 Clinical Criteria for UM Decisions, Element C Factors 1 and 2
  1. DISTRIBUTION:
  2. PHC Department Directors
  3. PHC Provider Manual
  1. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
  1. REVISION DATES:

Medi-Cal
11/28/01; 01/15/03; 10/20/04; 10/19/05; 10/18/06, 08/20/08; 08/18/10; 10/01/10; 05/16/12; 01/20/16; 08/17/16; 02/15/17; *03/14/18; 08/08/18

*Through 2017, Approval Date reflective of the Quality/Utilization Advisory Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

PREVIOUSLY APPLIED TO:

Healthy Kids MPUP3026 (Healthy Kids program ended 12/01/2016)
10/18/06; 08/20/08; 08/18/10; 10/01/10; 05/16/12; 01/20/16; 08/17/16 to 12/01/2016

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Inaccordance with theCalifornia Healthand SafetyCode,Section 1363.5,this policywasdevelopedwith involvement from activelypracticinghealth care providersandmeetstheseprovisions:

  • Consistentwith sound clinicalprinciplesand processes
  • Evaluatedand updated atleast annually
  • Ifusedas thebasis ofadecision to modify, delayordenyservices ina specific case, thecriteria will be disclosedto the provider and/orenrollee upon request

The materials provided areguidelinesusedbyPHC to authorize, modifyor denyservices forpersonswithsimilar illnesses or conditions.Specific care andtreatment mayvarydependingonindividualneedand the benefitscovered underPHC.

PHC’s authorization requirements comply with the requirements for parity in mental health and substance use disorder benefits in 42 CFR 438.910.

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