Opinion ID: 3010672
Heading Depth: 4
Heading Rank: 2

Heading: PRO NJ's Quality Review and Sanction Process

Text: PRO NJ has adopted the following procedures to determine whether a quality issue exists with respect to the care of a Medicare beneficiary. At the outset, a nurse employed by the PRO screens a medical record to determine whether a potential or possible quality question might exist. If the nurse determines that such a question exists, the case is referred to a physician-reviewer of the PRO, who then reviews the matter and determines whether there is, in fact, a potential quality issue. If the physician-reviewer determines that there is a potential quality issue, the PRO prepares a quality inquiry and issues it to the physician in question. The PRO also requests a response from the physician. The physician generally responds in writing to the quality inquiry by submitting to the PRO a response on the same notice form. Following receipt of the response form from the physician in question, the matter is once again reviewed by the physician-reviewer, who then determines whether there is a confirmed quality problem. If there is no quality problem, an acceptance notice is issued and no further action is taken. However, if there is a confirmed quality problem, the PRO may request further action on the part of a physician. Such action may include a referral to the Sanction Committee of the PRO, a standing committee of the PRO, for additional review and a determination as to whether or not a preliminary determination should be made that a sanctionable offense has occurred.7 _________________________________________________________________ 7. There are generally two types of sanctionable offenses: a gross and flagrant violation and a substantial violation in a substantial number of cases. The former offense means that a violation of an obligation has 12 In the event that the Sanction Committee makes a preliminary determination that a sanctionable offense occurred, a notice is issued to the physician in question, along with an invitation to meet with the PRO of the New Jersey Sanction Committee (in the case of a gross and flagrant violation) or to respond in writing (in the case of a substantial violation). If a meeting is held with the Sanction Committee, a court reporter is in attendance. Also in attendance is the physician in question, the physician's attorney (if desired), the physician's expert witnesses (if any), and members of the Sanction Committee together with supporting staff. Following the sanction meeting, the Sanction Committee deliberates and reaches a determination as to whether or not the previous preliminary determination should be affirmed, modified, or reversed. In the event that the preliminary determination is affirmed, the physician is given an opportunity to enter into a corrective action plan, assuming that the physician is willing and able to meet his statutory obligations and the matter before the committee is not considered egregious in nature. Communications between the PRO and the physician then follow, at which time the parties will generally agree upon an approved educational plan which is then implemented by the physician. In cases considered egregious, or in cases where there is an established pattern of care, the PRO may refer the matter to the New Jersey Office of Inspector General. In that case, a sanction report is prepared and issued to the Office of Inspector General, which contains all of the information upon which the Sanction Committee relied in reaching its determination. A copy of the sanction report is provided to the physician in question, who has a right to _________________________________________________________________ occurred in one or more instances which presents an imminent danger to health, safety, or well-being of a program patient or places the program patient unnecessarily in high-risk situations. 42 C.F.R. S 1004.1. The latter means a pattern of providing care . . . that is inappropriate, unnecessary, or does not meet recognized professional standards of care, or is not supported by the necessary documentation of care as required by the PRO. Id. 13 respond to the Office of Inspector General within thirty days of receipt. At the conclusion of a quality inquiry with PRO NJ, the physician in question will generally have substantial documentation in his or her file. This documentation may include: (1) the initial quality assurance inquiry; (2) the physician's response; (3) additional correspondence regarding the quality issue; (4) a sanction notice, which includes a quality assurance review sheet, a medical director's committee review sheet, and other information upon which the PRO bases its preliminary determination regarding a sanctionable offense; (5) the physician's written response to the sanction notice; (6) various correspondence related to the sanction process; (7) a determination by the Sanction Committee; (8) correspondence regarding the corrective action plan; and (9) a certification of completion of the corrective action plan.