Substantial

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Substantial

  1. 1. SUBSTANTIAL VIOLATIONS IN A SUBSTANTIAL NUMBER OF CASES A HORROR STORY Presented by: Dr. Jeffrey Deitch & Melody Petrul, RN
  2. 2. Practical Lessons Learned • Patience • Documentation is key • Utilize your attorney and Medical Director • Collaborate with other QIOs • Utilize the OIG • Keep your Project Officer informed • EXPECT THE UNEXPECTED
  3. 3. Case History • June 2000, referral received from the carrier • 56 cases were referred • Physician-reviewers identified quality concerns for the attending physician and the physician assistant
  4. 4. Case History (cont.) • Quality pending letters sent on 20 cases/patients • Responses received on 2/20 from the doctor • 18/20 cases finalized with Quality concerns identified • No requests for re-review
  5. 5. Case History (cont.) • Routine case review profile noted a pattern for the physician and physician’s assistant • Medical director, two physician-reviewers, and compliance manager met to discuss potential pattern • Pattern of inappropriate care identified, committee decided to proceed with Initial Sanction Notice
  6. 6. Concerns Identified • Use of three different types of corticosteroids in one injection to manage chronic pain • Injections of Nubain for chronic pain • Inappropriate or incomplete physical examinations for presenting complaints • Lack of timely referrals to specialists • Continued to prescribe pain medication to known drug seekers • Prescribing antibiotics for patients even when there was no indication of an infectious process
  7. 7. Initial Sanction Notice • Initial Sanction Notice of Substantial Violation in a Substantial Number of Cases sent to the attending physician and the physician’s assistant on May 23, 2002 • MPRO received a request for a meeting from the attorney representing the attending physician and the physician assistant • MPRO put meeting plans in place • Attorney cancelled meeting one week before, due to his schedule
  8. 8. Initial Sanction Notice (cont.) • MPRO rescheduled meeting with attorney • Attorney contacted MPRO, physician assistant due to have elective surgery and would be recuperating, wanted to reschedule • Discussed with MPRO’s medical director and attorney; decision was made to hold meeting with just the attending physician
  9. 9. Initial Sanction Notice (cont.) • Meeting conducted with attending physician and his attorney • MPRO participants included: Medical director, board-certified general practice physician- reviewers, and MPRO’s attorney • Court recorder
  10. 10. Initial Sanction Notice (cont.) • Committee met following the meeting • Decision to recommend a Corrective Action Plan (CAP) • Letter sent to attending physician, copied to his attorney requesting CAP • Received signed acknowledgement indicating intent to complete CAP
  11. 11. CAP • Within six months, attending submitted all of the requirements recommended for the CAP • Committee reconvened, except for MPRO attorney, and determined that CAP was successfully completed by the attending physician • Letter sent to attending physician, copied to his attorney advising that the CAP was successfully completed and no further action would take place
  12. 12. What About the Physician Assistant? • MPRO contacted attorney following the anticipated recovery period • Date for meeting set • Again meeting cancelled two days before • MPRO attorney notified • OIG called • Medical director consulted
  13. 13. Now What? • Letter drafted by MPRO and approved by MPRO attorney advising the physician assistant’s attorney and the physician assistant on requirements that must be met in order for MPRO not to take it to the next level • Received a letter back from attorney and physician assistant indicating the dates they could participate in a meeting • January 21, 2003, meeting was finally conducted
  14. 14. CAP Recommended • A letter was sent advising the physician assistant that completion of a CAP would be required • A signed agreement from the physician assistant was received by MPRO on March 29, 2003 • The CAP was to be completed by September 31, 2003 • No CAP received
  15. 15. Now What? • Discussed with medical director and MPRO attorney • Tried to call physician’s assistant, no answer • Medical director discussed case with physician’s assistant’s attorney • Letter sent advising physician assistant of importance of completing CAP
  16. 16. Second Notice • November 13, 2003, Second Notice of Substantial Violation in a Substantial Number of Cases sent • Notice sent to physician assistant’s home by regular US mail and certified mail, return receipt requested • Certified Notice returned unclaimed
  17. 17. Now What? • Discussed with MPRO attorney • Re-sent Notices with cover letter at the end of December 2003 • Notice sent by regular US mail, Fed-ex, and certified mail return receipt requested • US mail and Fed-ex returned to MPRO with notation on envelopes “MOVED” • Certified mail, returned with signature of someone from that address and family
  18. 18. Now What? (cont.) • Discussed with medical director, MPRO attorney • Discussed with OIG:  Was the Second Notice actually considered delivered?  If it was, does a new panel of physicians and physician assistants have to convene to decide the final outcome?
  19. 19. Conclusion: Patience
  20. 20. Conclusion (cont.) • Collaborate with other QIOs • Refer to the QIO manual and reference the Code of Federal Regulations • Have an attorney present • Document • Communicate with your attorney, medical director, the OIG, and your project officer • EXPECT THE UNEXPECTED
  21. 21. Questions

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