Systems Review. If Rehab’s Discovery Sample identifies an Error Rate of 5% or greater, Rehab’s IRO shall also conduct a Systems Review. The Systems Review shall consist of the following:
a. a review of Rehab’s billing and coding systems and processes relating to claims submitted to Federal health care programs (including, but not limited to, the operation of the billing system, the process by which claims are coded, safeguards to ensure proper coding, claims submission and billing; and procedures to identify and correct inaccurate coding and billing);
b. for each claim in the Discovery Sample and Full Sample that resulted in an Overpayment, the IRO shall review the system(s) and process(es) that generated the claim and identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the claim.
Systems Review. The Construction Administrator will conduct reviews of proposed roof, structural, mechanical, electrical, plumbing, conveyance, sprinkler, telecommunications, and life safety systems, and will consider initial cost, availability, impact on the overall program, comfort and convenience, long-term maintenance and operating costs, and impacts on schedule.
Systems Review. If the Friendship Entities’ Discovery Sample 1 or Discovery Sample 2 identifies an Error Rate of 5% or greater, the Friendship Entities’ IRO shall also conduct a Systems Review. The Systems Review shall consist of the following:
a. a review of the Friendship Entities’ billing and coding systems and processes relating to claims submitted to Federal health care programs (including, but not limited to, the operation of the billing system, the process by which claims are coded, safeguards to ensure proper coding, claims submission and billing; and procedures to identify and correct inaccurate coding and billing);
b. for each claim in the Discovery Samples and Full Samples that resulted in an Overpayment, the IRO shall review the system(s) and process(es) that generated the claim and identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the claim.
Systems Review. If either Error Rate for the Discovery Sample is 5% or greater, Good Shepherd’s IRO shall also conduct a Systems Review with respect to the applicable review. The Systems Review shall consist of the following:
a. a review of Good Shepherd’s systems and processes for determining and documenting a Medicare beneficiary’s eligibility for the hospice benefit, including the processes for certification and recertification of beneficiaries, and how those systems and processes were implemented at Good Shepherd;
b. a review of Good Shepherd’s systems and processes for determining and documenting the medical necessity for the Level of Services provided to a Medicare beneficiary implemented, and how those systems and processes were implemented at Good Shepherd; and
c. for each Medicare beneficiary determined to be ineligible for the hospice benefit or to receive a Level of Services that was not medically necessary (e.g., continuous care), the IRO shall perform a detailed review of the system(s) and process(es) that resulted in Good Shepherd’s erroneous determination that the beneficiary was eligible for the hospice benefit or that medical necessity existed for the Level of Services provided, to identify any problems or weaknesses that may have resulted in the identified error(s). The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) for determining eligibility for the hospice benefit or medical necessity for the Level of Services provided.
Systems Review. Observations, findings, and recommendations on possible improvements to the system(s) and process(es) that generated the Overpayment(s).
Systems Review. If Tri-County’s Discovery Sample identifies an Error Rate of 5% or greater, Tri-County’s IRO shall also conduct a Systems Review. The Systems Review shall consist of the following:
a. a review of Tri-County’s billing and coding systems and processes relating to claims submitted to Federal health care programs (including, but not limited to, the operation of the billing system, the process by which claims are coded, safeguards to ensure proper coding, claims submission and billing; and procedures to identify and correct inaccurate coding and billing);
b. for each claim in the Discovery Sample and Full Sample that resulted in an Overpayment, the IRO shall review the system(s) and process(es) that generated the claim and identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the claim.
Systems Review. The Systems Reviews shall assess Indivior’s systems, processes, policies, and procedures relating to the Covered Functions. If there are no material changes in Indivior’s relevant systems, processes, policies, and procedures, the Systems Reviews shall be performed for the first and fourth Reporting Periods. If Indivior materially changes its relevant systems, processes, policies, and procedures, the IRO shall perform a Systems Review for the Reporting Period in which such changes were made in addition to conducting the Systems Review for the first and fourth Reporting Periods, as set forth more fully in Appendix B.
Systems Review. The Peer Review Consultant shall conduct a review of the current processes undertaken by KDMC with respect to medical staff peer review, medical staff credentialing and privileging, and medical staff training and discipline (Systems Review). The Systems Review shall consist of a thorough review of KDMC’s policies and procedures, practices, bylaws, meeting minutes, case reviews, corrective actions, disciplinary records, medical staff participation, ongoing quality- monitoring data, and oversight by KDMC’s senior management and the Board of Directors of KDMC. Such review may include, but shall not be limited to, document review, interviews, observation of meetings, trainings, data review, benchmarking, analysis of utilization data, and presentations. The Peer Review Consultant shall perform all components of the Systems Review. The Systems Review shall be performed in the first Reporting Period of the CIA, and shall be completed within 60 days of the end of the first Reporting Period.
Systems Review. Consultant will conduct an initial, comprehensive review of the current investment program. The review will include the following:
(a) an assessment of the program’s current design;
(b) a review of the current portfolio structure;
(c) an evaluation of the current investment manager lineup; and a written report containing observations and recommendations for the program where appropriate.
Systems Review. If CHSI’s Discovery Sample at any CHSI Covered Facility Selected for review identifies an Error Rate of 5% or greater, CHSI’s IRO shall also conduct a Systems Review. The Systems Review shall consist of the following:
a. a review of CHSI’s admissions, utilization review, billing and coding systems and processes relating to claims submitted to Federal health care programs (the processes and systems used to decide the appropriate level of care, utilization review processes and systems, the operation of the billing system, the process by which claims are coded, safeguards to ensure proper coding, claims submission and billing; and procedures to identify and correct inaccurate coding and billing);
b. for each claim in the Discovery Sample and Full Sample that resulted in an Overpayment, the IRO shall review the system(s) and process(es) that generated the claim and Community Health Systems, Inc. 3 Corporate Integrity Agreement - Appendix B identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the claim.
