Chapter 8: Utilization Review for Post-Acute Rehabilitation Residential Services for Traumatic Brain Injury

8.1 Overview

Compliance and quality reviews help ensure that the appropriate scope and level of services are provided to CRS participants. The compliance and quality review may be performed as a clinical or purchasing review. Compliance and quality reviews can occur with any service array provided or paid for by the CRS program.

8.2 Review Types

  • Clinical — Review of services when the participant is actively receiving services within a specified date range or after delivery or discontinuation of services. These reviews ensure that services are provided as recommended by the Individualized Program Plan and interdisciplinary team.
  • Purchasing — Review of participant case file to verify justification and delivery of purchased goods and services based on purchasing guidelines and policy.

8.3 Review Processes

Reviews of a participant’s records, services, and billing can occur from the point of entry into the CRS program until after the participant ends or completes treatment and may include prospective, concurrent, and retrospective review activities.

The purpose of a CRS quality and compliance review is to:

  • ensure the program fiscal integrity of the provider;
  • address the state laws and regulations that require program funds be spent only as allowed; and
  • ensure that services are provided based on medical necessity and are continued based on their efficacy.

A participant’s records may be chosen for review through a random sample or based on necessity, as noted by CRS program staff members.

8.4 Clinical Reviews

During a prospective review, services are reviewed before they are authorized to determine if the participant, the current processes, or both were followed.

The purpose is to ensure that:

  • a participant meets eligibility requirements;
  • services will meet the participant’s needs; and
  • CRS program staff members are following CRS policies and procedures.

The review may include:

  • a review of intake and assessment information;
  • a diagnostic interview;
  • a review of the participant’s records that support eligible diagnosis or diagnoses;
  • a determination of eligibility by the CRS counselor;
  • a review of the participant’s Individualized Written Rehabilitation Plan;
  • a review of the participant’s records documenting the care of the participant provided by the provider, paraprofessionals and professionals;
  • medical and nursing assessment and diagnoses;
  • changes in treatment strategies based on data or assessments;
  • a review of the interdisciplinary team meeting summaries;
  • participant schedules;
  • a review of the consents from the participant;
  • a review of the participant restraints reports;
  • on-site visits and outings;
  • assessments made at the request of or by the CRS counselor;
  • interviews held with the participant, participant’s family or guardian; and
  • discharge planning.

8.5 Purchasing Reviews

Purchasing reviews can occur during or after services have been provided and purchased.

The purpose is to ensure that:

  • a participant is receiving or has received services based on medical necessity;
  • the services occur or occurred in the frequency and duration specified in the Individualized Written Rehabilitation Plan and the treatment outcomes meet or met the participant’s needs; and
  • CRS program staff members are following billing requirements from CRS policies and procedures and providers are rendering services as determined by the CRS counselor and participant.

The review may include:

  • a review of the Individualized Program Plan and Individualized Written Rehabilitation Plan;
  • therapy assessments and therapy notes, along with treatment plans and treatment data;
  • review of medical necessity;
  • review of explanation of benefits or denials;
  • review of number of hours or days of service provided; and
  • review of documentation confirming all billing activities in accordance with CRS policy and standards.

8.6 Review Outcomes

Recoupment of Overpayments

Recoupment is required if the results of a utilization review indicate overpayment for services delivered, payment made for services not delivered, or payment made for services provided without preauthorization.

The agency notifies the provider in writing about the overpayment identified and explains the method of recoupment to be used.

Administrative Actions and Sanctions

The administrative actions or sanctions from a utilization review may result in one or more of the following being taken by the agency:

  1. Closure of the review with written notification to the provider.
  2. Discussion and interpretation of the results of the review with the provider.
  3. Referral to the appropriate state licensing board or to the Texas Office of the Inspector General.

8.7 Appeal Process for Providers

After a utilization review, the CRS program gives the provider a report of the findings.

The provider may appeal the report within 30 days of receiving the findings by submitting a written report that includes supporting documentation disputing the findings.

The CRS program reviews the provider’s appeal and sends the outcome of the review to the provider.