Peer Review Policy

Policy: Peer Review

Policy Number: 300 Policy Section: Quality
Owner: Cynthia Grant Approved By: Cynthia Grant
Effective Date: 3/15/2022 Date of Last Review: 07/18/2022

 

SUD Specialty Group -- CA; Mental Health Specialty Group, P.A.; Mental Health Specialty Group NJ, PC; and Mental Health Specialty Group KS, P.A. (collectively, the "Group") contracts with Path CCM, Inc. d/b/a Rula Health ("Rula") for management and administrative support services. This policy applies to the Group and Rula.

 

Policy Statement

This policy develops a comprehensive peer review process to ensure treatment and service records adhere to required standards. The purpose of peer review is to provide routine evaluation of practice standards to examine clinical care and service delivery to determine if there are opportunities for improvement that will produce the highest quality of care. 

 

Applicability:

This policy applies to team members who provide treatment services to patients. For purposes of this policy, the Group’s and Rula’s team members include individuals who would be considered part of the workforce such as employees, independent contractors, business team members, and other persons whose work performance is under the direct purview of Rula or the Group’s  business practices. 

 

Definitions

Peer Review:  a process in which trained, qualified, licensed professionals evaluate the clinical competence, documentation practices, and the quality and appropriateness of care delivered by service providers by way of reviewing patient records.   

 

Peer Reviewer:  any physician, nurse practitioner, social worker, psychologist, or professional counselor who meets basic qualifications and has the clinical expertise and training to conduct an evaluation of documentation.  The peer involved in the review shall have the same level of license/credentials, at minimum, as the person involved in the delivery of service being reviewed.  

 

Provider: an individual who is qualified by licensure and experience to provide services to patients and who is employed or contracted by the Group to provide those services

 

Policy

  1. Clinical chart review protections
    1. Clinical chart reviews are considered peer review, the confidentiality of which is protected by HIPAA.  Clinical chart reviews are used only for ongoing quality improvement efforts related to the necessity, appropriateness, or quality of services rendered to a patient, or the qualifications, competence, or performance of a provider. 
    2. The record of the clinical chart review, including but not limited to to the associated review form, the data collected, and the resulting reports, findings, and conclusions are confidential and are not part of the designated record set, are not shared externally, are not public record, are not discoverable, and shall not be used as evidence in a civil or administrative proceeding. 
  2. Clinical chart review may be completed or requested for various reasons, including, but not limited to:
    1. Review of a specific provider based on issues identified by a patient, their family or on behalf of an individual represented by an advocate, a payer, the Complaint form and/or any issue brought to the attention of the Quality team. 
    2. A provider may request assistance from the Rula peer review team to review specific patient charts or an aggregate of patient charts focused on a specific concern. 
    3. Routine (monthly) monitoring occurs by choosing a random sample of 411 patient charts from the eligible population. The eligible population are those clients who have been seen within the month prior to the month the peer review is completed. The sample size of 411 patient charts was chosen based on NCQA’s recommendation for sample size collection. It is based on a statistical estimation of providing an 85% chance of identifying a 5% difference between patient charts. The number 411 is considered a statistically valid sample size, no matter the size of the eligible population. 
  3. Documentation of reviews and results
    1. Peer review findings will be documented in a format that fits the request.  
    2. Routine monitoring of charts will be documented using a Peer Review Form referenced in the attachment section of this policy.
    3. Results of clinical peer review will be sent to the appropriate party for the purpose of quality/practice improvement.  The information contained in the peer review may be incorporated into decision-making related to the provider’s contract. 

 

Attachments: 

A: Clinical Peer Review Form for therapists

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