Payment Error Prevention Program PEPP

1
A PROactive Method to Increase PRO
Responsiveness to Beneficiaries
2002 AHQA Technical ConferenceDallas, TX
Cheryl A. Cook, RN Manager, Case Review
2
Background

• Call centers answers approximately 1500 calls
  per month
• 4 of calls result in Quality of Care (QOC) case
  review
• Many callers are emotional and have unrealistic
  expectations
• Increased staff resources needed
• Opportunity to educate callers on QOC process

3
Objectives

• Improve beneficiary/caller satisfaction
• Improve QIOs responsiveness to beneficiaries
• Provide education in order to reduce number of
  emotional callers

4
Setting

• QIO Call Center
• Is part of the Case Review Department
• Employs Social Worker, Hispanic Representative
  and Psychologist

5
Development of Interventions

• Formulate interdisciplinary team
• Developed vision to assist beneficiaries with
  questions/concerns
• Team adopted educational approach to problem
• Designed standardize information to be given to
  callers
• Designed evaluation tool to determine
  effectiveness of presented material

6
Implementation of Interventions

• On initial call, Helpline team provides education
  on processes including
• role of QIO
• review and disclosure and
• helps establish realistic expectations/goals
• QOC Form mailed to beneficiary/caller, along with
  FAQ about QOC reviews

7
Implementation of Interventions

• Within days of initial call, Helpline staff
  recalls beneficiary/caller
• Evaluation of beneficiary/callers knowledge is
  assessed
• Did they understand information provided on
  initial call?
• Evaluation tool completed

8
Baseline Results

• QIO called 25 QOC callers in March 2001
• All received education regarding process
• Baseline measurement indicates 72 overall
  satisfaction rating
• Subsequent months show steady increase in
  satisfaction rating

9
Baseline Graph
100
Total called 17
100
88
90
80
76
80
70
65
62
60
53
50
50
47
50
38
40
35
30
24
20
20
12
10
0
Do you
Do you
Do you
Did the hotline
Do you
Was it explained
Did we meet
Was our staff
understand what
understand that
understand that
staff inform you
understand that
that FMQAI
your
friendly and did
FMQAI does?
FMQAI employs
FMQAI is
that FMQAI
we work with
would call you
expectations?
they explain the
RNs and
unable to release
does not punish
those providers
from time to
information in a
specialized
any information
physicians,
to improve the
time in order to
way in which
physicians to
without consent
hospitals, etc. for
quality of care
give you a status
you can
perform the
from you and
any issues
for future
report(s) on your
understand?
medical record
your physician?
found?
patients?
complaint?
Yes
review?
No
Overall 72 satisfaction rating
10
Current Results

• Currently, 97 overall satisfaction
• Increase staff sensitivity to callers needs
• Team members developed a sense of helping the
  beneficiary.

11
Current ResultsOverall Satisfaction
100
100
100
100
100
100
100
94
100
82
90
80
70
60
50
40
30
18
20
6
10
0
Do you
Do you know
Do you
Do you
Did the helpline
Was it explained
Are you aware
Was our staff
Did the
understand what
how FMQAI will
understand that
understand that
staff inform you
to you that
that there are
friendly and did
information
FMQAI does and
process your
FMQAI employs
FMQAI cannot
that FMQAI does
FMQAI would
some occasions
they provide
provided meet
how they work
complaint?
RNs and
release any
not punish
provide updates
when with your
information in a
your
with the
specialized
information
physicians,
on the status of
consent FMQAI
way which you
expectations?
Medicare system.
physicians to
without consent
hospitals, etc. but
your complaint
will refer your
could
perform the
from you and
rather FMQAI
via mail?
case to other state
understand?
medical record
your physician.
works with
or federal
reviews?
providers to
agencies for
improve their
further
Yes
quality of care?
investigation?
No
No Answer
Total Calls 17
12
Cummulative Graphof Overall Satisfaction
98
97
100
95
95
89
90
80
73
70
60
50
40
30
20
10
0
March (Baseline)
April - May
August
September
October
November
13
In Summary

• Taking a PROactive approach to beneficiary
• complaints has
• educated beneficiaries on QOC process
• reduced number of repeat hostile callers
• Team members developed a sense of helping
  beneficiaries/callers.

14
Attachments

• Initial Information Given to Beneficiary
• Follow Up Questionnaire
• Frequently Asked Questions About Medicare Quality
  of Care Complaints

15
How to contact
Cheryl Cook, RN 4350 W. Cypress Street, Suite
900 Tampa, FL 33607 phone [phone] ext.
3545 phone [phone] email
flpro.ccook_at_sdps.org