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CRS85894Apage21
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CRS85894Apage21
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cns-19 West Virginia iThe relatives of an indigent person, who are of sufficient ability, shall be liable to support such person in the manner required by the depart- ment of welfare [department of human services] and to pay the expenses of burial when he dies, in the following order: (1) The children. (2) The father. (3) The brothers and sisters. (4) The mother. The commissioner may proceed
CRS85894Apage15
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CRS85894Apage15
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...................... 101 72 ‘ 58 s 50 36 29 2 14 0 0 O 740 to 869.... ................ .. 130 101 86 79 65 9 58 43 29 14 0 870 to 1024.................... 144 1309 115 108 94 86 72 ‘ 58 43 29 1025‘u>1179 ............... w 144 144 144 144 130 123 108 94 79 65 1180 to 1339 ................ .. 144 144 144 144 144 144 144 130 115 101 1340 and up ............ ..,. 144 144 144 144 144 144 144 144 130 Miss. CodeAnn. § 43
CRS85894Apage22
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CRS85894Apage22
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~.... win. a ‘H Ii. V?
CRS87258EPWpage40
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CRS87258EPWpage40
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medical practice differences from State-to-State. V flj Wennberg, J. E. Dealing with medical practice variations a proposal for action. Health Affairs. v. 3, no. 2. Summer, 1984. pp. 6-32; i~ i *
CRS87258EPWpage28
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CRS87258EPWpage28
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CRS-22 TABLE 1. (continued) Comparison of 1984 Scope of work To 1986 Scope of Work Review Area 1984 1986 Validation of Objectivesi Hospital No- tices Specialityi ihospital Review Admission Pattern Monitoring Intensified Review Community Outreach Not in contracts. 100 percent where patient or physician disagrees. 100 per- cent where patient is liable. 10 percent of remaining. Proposed by each PRO
CRS87258EPWpage16
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CRS87258EPWpage16
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CRS*l0 III. MAJOR PROGRAM FEATURES if A. General Overview Hospitals are required to enter into agreements with Peer Review Organi- zations (PROS) as a condition for receiving payments under Medicare's prospective payment system for inpatient hospital services. PROs review the services provided to Medicare patients to assure that services are medically necessary, provided_ in the appropriate
CRS87258EPWpage06
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CRS87258EPWpage06
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CRS87258EPWpage34
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CRS87258EPWpage34
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the limited or basic levels) suggest Problems in quality of care, the level of review could be increased to the third level, "intensified reviewi"iiUnder this level, the samples of cases reviewed would be increased even more; for exampley 100 percent of all cases having any of 13 conditions, 6 percent of alladmissions, and 100 percent of all readmissionsg i yt HMOs and CMPS would move from one
CRS87258EPWpage32
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CRS87258EPWpage32
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that risk-contracting plans may reduce their utilization and costs such that the quality of care provided willdecline. In order to qualify for a risk contract, the HMO or CMP must have an on-going internal quality assurance program. Prior to the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), sthere was no specific legislation requirement for any independent, outside review of services
CRS87258EPWpage21
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CRS87258EPWpage21
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working days for all other cases. A beneficiary has further appeal rights, including an administrative hearing ibefore an Administrative Law Judge (where the reconsideration determination is adverse and the amount in controversy is at least $200), and judicial review _(where the decision in the administrative hearing is adverse and the amount in controversy is at least $2,000). The beneficiary must file
CRS87258EPWpage27
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CRS87258EPWpage27
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during contract period). Not in contracts. S Objectives. Based on PRO data from first 90 days of generic quality screen review. HCFA-identified outliers. Broader objectives. 3 percent random sample (includes 1 and 2 dayst stays). Pacemakers plus 4 pro~ cedures proposed by PRO. 100/percent preadmis* sion (see above). Same but lower level of review. Allrreadmissionsrwihin 15 days. Same. DRC 468
CRS87258EPWpage57
Title
CRS87258EPWpage57
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CRs—s1 SOUTH CAROLINA PRO: METRDLINA MEDICAL FOUNDATION DNE CHARLOTTETOWN CENTER . SUITE 150 ‘CHARLOTTE NC 28204 PHONE 7DA—373-1545 CONTRACT# SUD—86~0602 PRO CONTACTS EXEC. vICE PRESIDENT DAN CARRIDAN PRES. RICHARD KERECKMAN,M.D.R DECIN CDNTRACT D7/DI/as END CDNTRACT 06/30/88 R0 PROJECT OFFICER: CLYDE THOMAS % 404-331-OO53 OSOUTH DAKOTA PRO: SOUTH DAKOTA FOUNDATION FOR MEDICAL CARE 608 w
CRS87258EPWpage37
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CRS87258EPWpage37
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CR5-31} D. Second Surgica1 Opinionsp Section 9401 of The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires PROs to perform 100 percent pre-procedure review on at least n10 elective surgical procedures. PROS are authorized to require second opinions as part of the pre-procedure review pyocess if it is warranted. The‘ PRO may approve or disapprove a procedure as reasonable
CRS87258EPWpage68
Title
CRS87258EPWpage68
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CRS87258EPWpage53
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CRS87258EPWpage53
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BRIER HILL COURTN,BUILDING J EAST BRUNSWICK NJ D8816 RH0NE 201-238-5570 C0NTRACT# 500-87~054D PRO CONTACTS:EXEC.DIR. MARTIN R.MARC0LIEs PRES. 0AvI0 KIN0sLv,M.0. EECIN CONTRACT I0/01/as EN0 CONTRACT 09/30/80 R0 PROJECT OFFICER: vIvIAN z.0IR0ux 2I2-2sa-2003 NEW MEXICO RR0: NEw MExIC0 MEDICAL REvIEw ASSOCIATION 707 ER0A0wAv N.E.,suITE 200 P.0. BOX 9900, ~ ALRu0uER0uE NM 87106 PHONE 505-342-5235 CONTRACT
CRS87258EPWpage61
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CRS87258EPWpage61
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CRS87258EPWpage01
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CRS87258EPWpage01
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L____\._ \‘1.Ic5_/:_.2- / R ;z,{~S’“‘7'- 6PM) e 87-258 EPW Congressional Research Service . The Library ofCongress % Washirigton, I 4 - . _ 4 . -... llnit AUG 16 1994 WAashmgteon U%navers1tye Libraries! St. Louis, MO 53130 THE PEER REVIEW ORGANIZATION (PRO) Paocmxm e Prepared for the use of the Senate Committee on Finance e e Joseph.A. Cislowski e e Analyst in Social Legislation &
CRS87258EPWpage54
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CRS87258EPWpage54
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CR8 -4 8 NEw YORK RRD: EMPIRE STATE MEDICAL SCIENTIFIC AND EDuC.EDuNDATIDN,INC. A20 LAKEVIEW RDAD BOX 5434 LAKE SUCCESS NY IIDA2 PHONE 515-437-8134 CONTRACT# 500-86-D531 IPRO CDNTACTS:ExEC.DIR. JOHN D.RDDESTA RRES.DAVID BENFORD,M.D. BEGIN CDNTRACT D9/01/86 END CDNTRACT2 D8/31/88 RD RRDJECT DEEICER: STEVE LISKER 2l2+264+468UT NORTH CAROLINA RRD: MEDICAL REVIEW OF NDRTH CAROLINA SUITE 200, P.0.BOX
CRS87258EPWpage30
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CRS87258EPWpage30
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CRS-24 IV. OTHER RELEVANT ISSUES A. Out-offState Review The PRO contracts in 10 States are held by organizations based outside those States. Q] As listed in Appendix B, contracts for the following States (are currently held by out-of-State organizations (State in which the outrof- State PRO is based is in parentheses): Alaska (Washington) Delaware (West Virginia) District of Columbia (Maryland
CRS87258EPWpage72
Title
CRS87258EPWpage72
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IZIBRARY OF WASH1NG'roN ‘ * u~NtvE‘asITv A §‘r.L.ou1s Mo.

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