Validation/Appeals Process


Overview

CMS conducts a quarterly retrospective validation for all hospitals submitting data to the QIO Clinical Warehouse. Once the data is submitted, it will be subject to the following sampling and validation process.

The validation chart audit is performed to ensure that the data submitted to the QIO Clinical Warehouse accurately reflects the care and services recorded in the respective patient’s medical records. Five medical records across the four topics are selected at random for re-abstraction. CMS has contracted with Buccaneer Data Services (717.718.1230) as its Clinical Data Abstraction Center (CDAC), to perform the re-abstraction and to identify any discrepancies. Each hospital receives a summary report of the validation results from the CDAC. The role of Quality Insights is to provide hospitals with assistance, feedback, and education, especially in cases where the hospital did not meet the 80% validation threshold. Hospitals that score less than 80% on their validation may appeal the CDAC findings.


Validation Process

The chart audit validation process is performed to ensure the information collected is accurate. To do this, CMS has taken the following approach:

  • For each calendar quarter, all hospitals submitting abstracted data will be identified.
  • For each hospital, all abstracted charts will be enumerated.
  • A simple random sample of five charts will be identified from all hospitals with a minimum of six discharges in the QIO Clinical Warehouse. The sample is selected from all the cases submitted and is not topic-specific.
  • The CMS Clinical Data Abstraction Center (CDAC) will send the request for the sample charts to the medical records contact person. To update the contact person at your facility, please use the Provider Change of Contact Form. The records must be submitted by the deadline and must be the appropriate hospital stay. If the patient name, admission date or discharge date do not match the request, a decision of “Invalid Record Selection” will be assigned and will be made and could result in over 30 mismatches. You will not have the option to resubmit the chart not appeal the finding.
  • The CDAC will re-abstract the chart using the CMS Abstraction and Reporting Tool (CART). The relevant differences will be identified and the CDAC will assign a reason code to each difference noted.
  • Individuals in a QNet Feedback Role will be notified of the results of the re-abstraction, stored in the QIO Clinical Warehouse.
  • Hospitals will receive educational feedback, including an overall reliability rate and case details on each abstraction.
  • Based upon the CDAC re-abstraction, the percent agreement at the element level will be calculated. Hospitals that reach or exceed the 80 % pre-determined threshold would be considered to be supplying valid data for that quarter.

Accessing Validation Reports in QualityNet

  • Access reports via the secured site of QualityNet.
  • Proceed to the Run Reports section; under report category, choose Hospital Validation Reports.
  • Hospital Validation Reports are accessible by those hospital users designated in a QNet Feedback Role.
  • Case Selection Reports provides information on the five cases selected for validation.
  • Case Detail Reports provide overall results and CDAC reabstraction results for each element. A detailed explanation will be give for any mismatch.
  • Reports are generated and distributed through My QualityNet View Reports.

Reviewing Validation Results

CMS will notify hospitals via e-mail that the validation results are available in QNet on Mondays. It is essential that these reports be reviewed in a timely manner since hospitals scoring less than 80% that wish to initiate an appeal must do so and submit the appeal to Quality Insights of Pennsylvania within 10 business days. Once the reports are obtained, the facility may contact their project coordinator to review the findings. The decision to appeal should be made after reviewing the appropriate version of the Specifications Manual and QNet Quest.


Appeals

Hospitals that fall below an 80% validation rate have an opportunity to appeal the CDAC findings, if, after review with the project coordinator, the validation reports are believed to be inaccurate.

A hospital may not appeal the CDAC finding for situations where the CDAC noted missing information in the record and hospital did not originally submit that information. No additional documents may be submitted with an appeal.


Instructions for Initiating an Appeal

CMS requires that hospitals submit the appeal within 10 business days of receiving the results. After review of the findings, if the hospital determines that they would like to appeal, they must complete the Validation Results Appeal Form from www.qualitynet.org. The form must be transferred from the hospital to Quality Insights via My QualityNet. The form may not be faxed or sent regular mail due to the confidential nature of the appeal request. You will be notified of the results of your appeal via My QualityNet within 30 days.


Directions for Sending an Appeal to Quality Insights

In order to preserve confidentiality and expedite the appeal process, all appeal requests must be sent via My QualityNet. The steps are as follows:

  1. Administrator Login to My QualityNet
  2. Select SEND/RECEIVE under Exchange Files
  3. Select UPLOAD FILE WIZARD
  4. Choose group QUALITY INSIGHTS of Pennsylvania and open folder
  5. Select View Users at Quality Insights of Pennsylvania
  6. Highlight the name JULIE VOLZ and click on Add Selected Users button, and highlight the name DAWN STRAWSER, and click on Add Selected Users button
  7. Click on UPLOAD FILE(S) button
  8. Locate the Appeal file to upload
  9. Click on OPEN
You will receive the message, “Upload Successful: Click OK.”