Medical Review

Evaluating health care delivery

"TMF was able to evaluate quality of care and performance issues within the context of our unique care delivery system. They anticipated our needs and designed a report that was extremely useful to a variety of audiences."

-Ben G. Raimer, MD
Vice President for Community Outreach and Correctional Managed Care
University of Texas Medical Branch

When you need an unbiased, credible, third-party opinion, rely on TMF Health Quality Institute’s nearly 40 years of experience conducting medical record reviews. TMF has reviewed more than one million cases for the Centers for Medicare & Medicaid Services, the United States Department of Defense, the Texas Department of State Health Services and many private organizations. With board-certified physician reviewers representing all key medical specialties and a non-physician staff that includes experts in utilization/quality review and ICD-9-CM and CPT/HCPCS coding, no one is more qualified to provide medical peer review services.

TMF offers more than expert evaluation. With years of experience in quality improvement methodologies, we’re uniquely qualified to use the results of reviews to improve patient care. Our knowledge of practice guidelines, national standards and process improvement techniques enables us to provide customized training and recommendations for improving outcomes. We work with health care providers to map out a plan for successful and sustainable change.

Services

• Peer review – TMF offers peer review services for Medicare and Medicaid medical cases. Matched specialty review is an important aspect of this service. TMF has more than 125 physician reviewers representing more than 60 specialties and subspecialties, ensuring an appropriate physician is assigned to each case. All physician reviewers are in active practice, board certified and undergo a strict internal credentialing process.
• Quality/utilization review – TMF analyzes the quality of care and utilization of services provided to patients, equipping health care government agencies and providers with the information needed to offer more effective and efficient care. We use screening criteria to ensure consistent, accurate evaluation of medical records.
  
  TMF is certified as an Independent Review Organization and a Utilization Review Agent and is fully accredited by URAC for compliance with the Health Utilization Management and Independent Review Organization Accreditation Programs.
• Coding validation – Using established coding guidelines, TMF evaluates medical records to validate appropriateness of coding and assignment of Medicare Severity Diagnosis Related Groups to ensure accurate reimbursement.

Clients

TMF provides medical review services for federal, state and local government agencies, in addition to hospitals and other health care facilities through private contracts.

Accomplishments

Beneficiary Protection (Medicare)
As the Medicare Quality Improvement Organization for Texas under contract with the Centers for Medicare & Medicaid Services, TMF carries out a number of statutorily mandated review activities. These activities include review of quality of care provided to Medicare beneficiaries, review of appeals of certain provider notices and review of potential Emergency Medical Treatment and Active Labor Act violations (anti-dumping cases). Using data from case review activities, we identify quality-of-care problems and design quality improvement activities to help providers correct these problems.

During our most recent contract, TMF physician reviewers completed 618 reviews in response to Medicare beneficiary complaints. From the cases found to involve quality of care issues, TMF worked with health care providers and practitioners to initiate 168 separate quality improvement activities.

Medicaid Surveillance and Utilization Review
As a subcontractor to Affiliated Computer Services, TMF reviews statistical profiles of health care delivery patterns for Texas Medicaid providers and identifies utilization issues and potential fraud, abuse and waste. We establish statistical baselines of health care delivery, produce reports to monitor provider utilization with the Surveillance and Utilization Review Subsystem and perform retrospective medical record and prepayment reviews.
During state fiscal year 2009, TMF assisted the prime contractor in increasing the number of medical records reviewed by 37 percent, the number of educational letters sent to physicians by 55 percent and recoveries by 49 percent.

Indigent Care Services
TMF provides ongoing assessment and analysis of the utilization and quality of health care services provided to indigent clients for county hospital districts. We provide data on the cost-effectiveness of services and over/underutilization patterns that allow districts to make administrative decisions that change care processes to improve quality, decrease cost and increase the availability of services.

One district used data from TMF’s review of indigent care services to reduce rates of one- and two-day admissions by 50 percentage points and medically unnecessary back surgeries by 10 percentage points.

HIV Health Services
TMF conducts quality assurance review of HIV health services through contracts with multiple local governments. This work involves the evaluation of primary medical care services, including dental, optical and hospice services, funded through the Ryan White HIV/AIDS Treatment Modernization Act. Our review findings help grantees manage their resources for the greatest impact while ensuring the best care possible for those affected by HIV.

Using TMF’s review findings, three clinics improved their processes collectively to increase Pap smear screening rates by 45 percentage points and seasonal flu immunization rates by 33 percentage points.