Primary Care Physician (PCP) NDC (750973)

Minimum Qualifications:

• Be board certified in family practice medicine.
• Possess an active Pennsylvania medical license. If feasible, be in active clinical practice in the area in which the Resource is board certified at least sixteen (16) hours per month. Demonstrate an understanding of utilization review processes.
• Basic computer skills to include, but not limited, to Microsoft Office Products.

Description of Work/Duties:

Consultant in this position will serve as a physician reviewer for the Department of Human Services, Office of Medical Assistance Programs (Department). Consultant will:

1. Be available as a reviewer up to approximately 37.5 hours per week;

2. Be board certified in a Primary Care Specialty;

3. Possess an active Pennsylvania medical license;

4. If feasible, be in active clinical practice in the area in which the consultant is board certified at least sixteen (16) hours per month;

5. Demonstrate an understanding of utilization review processes; and

6. Possess basic computer skills, including familiarity with Microsoft Office programs.

Consultant will provide utilization and quality reviews of services for the Bureau of Fee for Service Programs, Bureau of Program Integrity, and Bureau of Long Term Care. Consultant will also provide clinical input into projects directed by the Department.

Consultant will conduct prospective, concurrent and retrospective review of any assigned adult and pediatric inpatient and outpatient medical cases covered by the Department including, but not limited to: inpatient admissions; procedures performed in a physician’s office, Short Procedure Unit or Ambulatory Surgical Center; home health services; medical supplies; and/or diagnostic studies or procedures. Consultant shall be responsible for making determinations regarding the medical necessity, place of service, appropriateness, compensability, and/or quality of care of services prescribed for and provided to Medicaid recipients. It will be the Consultants responsibility to review all requests thoroughly and make a qualified determination in accordance with Medical Assistance regulations and criteria.

In conducting reviews for the Department, Consultant will review all documents relevant to the type of assignment given, including but not limited to:

1. History and physicals including chief complaints and presenting symptoms;

2. Physician orders;

3. Plan of care/Treatment plan;

4. Physician progress notes;

5. Laboratory studies;

6. X-rays;

7. Physician consultation reports;

8. Surgical summaries;

9. Diagnostic tests and studies;

10. Death certificates;

11. Medications;

12. Nurses notes;

13. Therapy evaluations; and

14. Discharge summaries.

Consultant will complete all reviews within time frames specified in advance by each individual Bureau.

Depending on the type of case reviewed, consultant will be required to compile case findings, prepare summaries of case findings; make recommendations for case disposition, identify program violations; prepare appealed cases for hearings; and/or be available to testify at administrative hearings for cases under appeal. The Consultant will submit the above information to the Department using formats specified by each individual Bureau.

Consultant, when requested, will assist in the development of in-house training programs, medically necessary criteria, and quality of care indicators. Consultant may be asked to help the Department in determining if any changes should be made to criteria or regulations to better serve their clients.

Consultant will work at one or more of the individual Bureau’s offices. Consultant will be provided with a desk, computer, phone, and all items necessary for him/her to complete assignments.

On a weekly basis Consultant will complete and enter original time and attendance electronically via the Vector system. The Work Site Supervisor will verify the Consultant’s hours by approving the time sheets. Time and attendance sheets will contain the following information:

1. Consultant’s name;

2. Hours worked;

3. Start and end time; and

4. Time of break and work periods

Payment shall be made after services are actually rendered by the Consultant. If Consultant is unable to appear at the scheduled work site at the pre-determined times, notification must be made to the Work Site Supervisor either prior to date or on date of absence.

Consultant may be required to represent the Department at face-to-face or telephone hearings for cases they have reviewed that are under appeal. The Department anticipates that, on an infrequent basis, the Consultant may have to travel to participate in face-to-face hearings in state office buildings in major cities across Pennsylvania. Advance notice will be provided of the need to travel to hearing sites. Reimbursement for travel required by the Department, will be made in accordance with the Commonwealth of Pennsylvania’s travel regulations. Travel to and from the designated work site and travel between DHS and contractor sites within 10 miles of Harrisburg is considered commuting and does not qualify for mileage reimbursement.

In all cases wherein the Consultant has a personal relationship with any individual involved in the matter requiring consultative services, in all cases wherein Consultant has a personal interest in the matter requiring consultative or in any other situation where the Consultant might be perceived to have a conflict of interest, Consultant shall immediately notify the Department and recuse herself/himself from any further participation in the consultative process.

Consultant acknowledges that, in performing consultative services, Consultant shall be made privy to information of a confidential nature, including but not limited to information regarding the medical history of the client. Consultant hereby covenants to maintain the confidentiality of all such information, to the extent required by law and medical ethics. Consultant shall only disclose such confidential information to other medical experts to the extent necessary to provide the consultative services contemplated herein and only after prior notice to the Department of intent to so disclose.

Work Product Deliverables

Within time frames specified by each individual Bureau of receiving a request for review of services the Consultant will provide the Bureau with the following:

1. Statement of recommendation regarding the medical necessity, place of service, appropriateness, compensability, and quality of care of services prescribed for and provided to Medicaid recipients that includes the rationale used by Consultant in making the determination;

2. A case summary that includes all applicable information including but not limited to: patient name, medical assistance identification number (MAID), age, date(s) of service, diagnosis, Medical Assistance regulations violated or in question, and services/days approved, modified or denied; and

3. A summary of information used in making a determination, including but not limited to: medical record information, important dates, and any other information used buy the Consultant.

Administrative Deliverables

Prior to beginning work for the Department, Consultant will supply Vendor with the following credentials:

1. Copy of Medical License;

2. Copy of DEA Certification;

3. Copy of any applicable board certification;

4. Verification of ongoing clinical practice;

5. Verification of continuing medical education including dates, topics and credits earned for each educational session;

6. Attestation that no prohibitions, sanctions, or terminations have been levied on Consultant from Federal, State or other health programs in and outside of Pennsylvania;

7. Verification of malpractice insurance (copy of front page of policy); and

8. Documentation statement of any malpractice actions or settlements during the past year.

On an annual basis, the Consultant will provide to Vendor an updated status of items listed above.

Consultant will be required to meet, as a group, with other consultants and staff from the Department on a quarterly basis, (time to be scheduled by the Department) to review:

1. New and old regulations and criteria;

2. How the criteria/regulations can be adhered to under their specialty;

3. Review of work statements to verify objectives are being met;

4. Review volume of reviewed records;

5. Discussion of work production; and

6. Discussion of quality improvement initiatives.

The Consultant will be required to meet with the Department on an individual basis as needed. In addition, the Consultant will be required to meet yearly with the Department at which time a measurement of the Consultant’s performance and expectations will be reviewed. The yearly meeting will include but is not limited to the following items for discussion:

1. Quality of work product;

2. Time and attendance;

3. Criteria Consultant is basing reviews on;

4. Timeliness of reviews;

5. Consistency of reviews in appeals;

6. Preparedness for hearings;

7. Percentage of denials;

8. Percentage of denials upheld; and

9. Peer review and benchmark findings.

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