HCAC & OPPC MEDICAID INPATIENT HOSPITAL SETTINGS APRIL

Provider Preventable Conditions PPC (Provider - Preventable Condition) OPPC (Other Provider Preventable Condition) Any healthcare setting Includes wrong surgery/invasive procedures HCAC (Health Care - Acquired Condition) Inpatient settings Medicare HACs and wrong surgery/invasive procedures 2

 Other provider-preventable condition (OPPC): A condition occurring in any health care setting that could have reasonably been prevented through the application of evidence based guidelines that meet the criteria established under 42 CFR part ; Are defined to include at minimum, the three Medicare National Coverage Determinations (surgery on the wrong patient, wrong surgery on a patient, and wrong site surgery).  Health care acquired condition (HCAC): A condition occurring during an inpatient hospital stay, identified as a Medicare HAC, with the exception of deep vein thrombosis/pulmonary embolism related to total knee replacement or hip replacement in pediatric and obstetric patients.  Hospital-acquired condition (HAC): An undesirable condition occurring during an inpatient hospital stay. A list of conditions is identified in the Federal Register for Medicaid Regulations. Definitions 3

Effective Date May 1, 2012 HCACs and OPPCs 4

 Review of HCACs & OPPCs that occur during hospitalizations  Post payment claim-based analysis  Reporting to the Medicaid agency Scope of Services 5

Federal Register For Medicaid Regulations eQHealth RESOURCES 6

Limit the number of days certified only to those preceding the event and any additional medically necessary inpatient days for services unrelated to the event HCACs & OPPCs Occurring During Hospitalizations 7

Verification of the degree of reliability between reporting and actual claims submission. –Comparison of the information submitted to eQHealth to the “present on admission” (POA) indicator and ICD-9-CM codes on the submitted claim. Post Payment Claims-based Analysis 8

Upon identification of a discrepancy: –A request for an electronic copy of the medical record is sent via ; the record is to be submitted within 30 days of the request. Medical record received – review continues Medical record not received –Review is suspended; and –AHCA is notified Post Payment Claims-based Analysis Cont’d 9

 Frequency of occurrence by:  Type of HCAC or wrong surgery/invasive procedure  Provider  Provider reporting reliability  Provider specific patterns Reporting Results to AHCA 10

eQHealth is responsible for reviewing HCACs and OPPCs related to hospitalizations in all hospital settings. Review Process 11

 Provider reporting during submission of review requests  Identification by eQHealth during review Review Process 12

When a HCAC or OPPC is reported by a provider or identified by a nurse reviewer, the following actions are taken:  Determine if additional information is needed:  No – Proceed with review  Yes – Request additional information  HCAC or wrong surgery/invasive procedure:  No – Proceed with review  Yes – Refer to second level physician reviewer First Level Review 13

 The physician reviewer may:  Pend the request for additional information  Consult with the attending physician  Determinations:  HCAC or wrong surgery/invasive procedure  Whether inpatient days are solely for the treatment related to the incident Second Level Review Process 14

 Full Denial –  The incident occurred on the day of admission of the recipient to the hospital and care is solely for treatment related to the incident.  A recipient’s readmission (to the same hospital) occurs solely as a result of an incident related to a previous admission.  Partial Denial – Inpatient days following the occurrence are solely for the treatment related to the incident. Adverse Determinations 15

 In accordance with Agency policy, any party involved in the case may request a reconsideration of an adverse determination.  Requests for reconsideration will be reviewed by a physician reviewer not involved in the original case review. Reconsiderations 16

 Providers must report the:  Date of the occurrence  Nature of the specific event  Applicable ICD-9-CM code Provider Reporting Requirements - eQSuite 17

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Customer Service Nancy Calvert Director, Provider Education & Outreach RESOURCES 27