Case Study

From Concerned to Assured: How Chartis Clinical Quality Solutions Partnered with an Ambulatory Surgical Center to Ensure Sound Clinical Judgment and Appropriateness of Diagnosis and Treatments through an External Medical Necessity Review

3 minutes

The Client Challenge

While undergoing growth and expansion in its pain division, an ambulatory surgical center (ASC)’s leadership sought to ensure its new practitioners were adhering to the organization’s quality standards. They proactively identified pain stimulator implant procedures as a focus area.

Since treatment often involves pursuing alternative therapies first, followed by a trial of the implant when other options proved ineffective for pain management, an external evaluation of procedural medical necessity was a proactive effort to identify
potentially unnecessary procedures that may also have resulted in inappropriate billing.

MEDICAL NECESSITY REVIEW IMPROVEMENT OPPORTUNITIES
  • New medical service/procedure due diligence to ensure treatment appropriateness
  • Improve quality and effectiveness of patient care by eliminating unnecessary treatment
  • Reduce costs for patients, physician investors, and the facility
  • Lower potential legal risk

The Solution

The ASC worked closely with Chartis Clinical Quality Solutions to undertake a comprehensive medical necessity review covering several interventional pain medicine practitioners and nearly 100 outpatient procedures. Using a tiered approach, two board-certified, actively practicing, external physician reviewers first evaluated medical necessity for the trials followed by the permanent implant procedure. They reviewed all medical records and patient histories to determine whether symptoms were intractable and pain not relieved.

The reviewers used a standardized scoring methodology that assessed care as either appropriate, questionable, or not appropriate. For each procedure, reviewers identified opportunities for improvement in care, including diagnosis accuracy, clinical judgment/decision-making, technique, delay in diagnosis or treatment, and documentation. The ASC received a concise report that would enhance the organization’s continuous improvement efforts as well as supply data for ongoing tracking and trend analysis.

Our Approach

MATCH

MATCH

Identify external peer reviewers from an extensive network of actively practicing and board-certified practitioners

SELECT

SELECT

Utilize a randomization tool to select a sample of appropriate cases for review

EVALUATE

EVALUATE

Conduct independent review of records

SYNTHESIZE

SYNTHESIZE

Prepare comprehensive report, including a concise summary of findings

GUIDE

GUIDE

Provide post-review debrief and guidance for next steps

Client Impact

The ASC reviewers identified significant improvement opportunities through the medical necessity review. None of the procedures received a not appropriate score, but a large percentage received a questionable score. The findings illuminated areas where providers could improve documentation to support the medically necessary procedures more clearly for treatments performed. The report of findings also served as a guide for enhancing documentation that improved accuracy in coding and billing for both the facility and the physician.

Medical necessity reviews can improve quality of care by evaluating appropriateness of diagnosis and treatments performed
~ 100

Cases Reviewed

> 40 %

Reviewed Cases with Documentation Improvement Opportunities

3- 4

Weeks Time to Completion


How We Are Making Healthcare Better

Medical necessity reviews comprise a key element in an organization’s quality, safety, and cost improvement efforts. Utilizing external expertise assures objective, evidenced-based evaluations that can be used for reliably safe care in the future. ”

Sheri Winsper, RN, MSN, MSHA
Vice President, External Peer Review/Clinical Quality & High Reliability, Chartis Clinical Quality Solutions

Key Takeaways

Patient diagnosis and treatment decisions can be efficiently and proactively evaluated through an external medical necessity review that:
  • Teams with experienced external peer reviewers
  • Employs a proven, evidence-based review methodology and approach
  • Scores findings and identifies trends and improvement opportunities
  • Provides post-review support

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