Common use of Systems Review Clause in Contracts

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.