Finally, PROs must investigate all written complaints from beneficiaries about the quality of care rendered by hospitals (inpatient or outpatient), SNFs, HHAs, ASCs, HMOs, and CMPs. Here, the focus is on overuse of care or care that does not meet professionally recognized standards because PROs are barred from reviewing complaints involving underuse.

Community Outreach

The PROs must conduct programs to inform beneficiaries about Medicare PRO review and PPS, more specifically about the purpose of the PROs and PPS, types of PRO review, and their right to appeal a PRO determination. The PROs are also expected to devise ways to explain how they ensure the quality of care and respond to complaints from beneficiaries.

Provider Relations

The PRO program continues to stress “peer review”; in PRO terms, this is taken to mean physician advisors who practice in a setting similar to that of the reviewed physicians and/or who were trained in the appropriate discipline. It also calls for an “interaction plan” to enhance the relationships between the PROs and providers, physicians, and other practitioners. That plan must describe how physicians will be given opportunities to discuss problems or proposed denials and how the PRO will carry out educational efforts. The outreach activities for practitioners and institutional providers are similar to those required for beneficiaries (seminars; informational material; etc.).

The PRO is also required to publish and disseminate (at least annually) a report that describes its findings about care that does not meet Medicare obligations (i.e., necessary, appropriate, and of acceptable professional standards). This task mirrors the requirement that DHHS should submit to the Congress an annual report on the administration, impact, and cost of the program; such reports have not been published to date, however.

Data Acquisition, Sharing, and Reporting

Rules governing PRO data acquisition, sharing, and disclosure are complex and open to different interpretations. PROs can obtain any records and information pertaining to health care services rendered to Medicare beneficiaries that are in the possession of any practitioner or provider in the PRO area. Often a quality problem may be adequately handled for Medicare patients only by addressing it for all patients; if authorized by the practitioner or provider, PROs can gain access to non-Medicare patient records.11

Generally, information or records acquired by a PRO are confidential12

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