HCQM News and Updates

Happy Thanksgiving!

We would like to take this opportunity to wish you and your family all the best as you celebrate during this special season of giving thanks!

We are thankful for our Diplomates and Members for sharing your journey in health care excellence with us and for continuing to improve the quality and safety of health care!

Our thoughts are with all those celebrating away from their family during the season. Also, take a moment to honor those serving in our armed forces who cannot be with their families; join us in wishing them a safe return.

The ABQAURP office will be closed beginning at 12:00 P.M. EST on Wednesday, November 23rd and will reopen on Monday, November 28th at 7:00 A.M. EST.

With much thanks,


Holiday Schedule 

The ABQAURP office will be closed the week of December 26th. We will reopen on Monday, January 2nd. All calls and emails will be returned at the first of the year. Happy Holidays!

CHCQM Diplomate Achievement Award

We are now accepting applications for the 2023 CHCQM Diplomate Achievement Award. 

To recognize the achievements of our extraordinary Diplomates, ABQAURP presents the CHCQM Diplomate Achievement Award bi-annually in conjunction with our Annual Health Care Quality & Patient Safety Conference. 

ABQAURP presents the Award to recognize the Diplomate that embodies the values of the medical profession through leadership, service, excellence, and integrity; demonstrating their commitment to advancing our mission to improve the quality of health care! The award will identify leaders whose outstanding initiatives have led to measurable change in patient safety outcomes, provider and/or patient engagement, and overall quality improvements. 

Submissions must be received by March 1, 2023.

Apply or encourage a CHCQM colleague to apply today!

Diplomate Recertification Reminder 

Diplomates that are due to recertify by December 31, 2022, register now to complete online courses before the end of the year! To use CME/CE credits already earned, register now to update your recertification. Please CLICK HERE for all of your recertification options. 

CE Spotlight Course

Aligning Care & Decisions to Older Adults' Health Goals 

Cheri Lattimer, RN, BSN
Executive Director, National Transitions of Care Coalition 

In the U.S., the population of older adults with complex health care needs is growing rapidly. For older adults, health care can be complicated. They are more likely to experience duplication of services, multiple transitions between care settings, harm from medications, and lack of planning that incorporates the goals of patients and their families. Age-friendly care teams assess their current workflows to understand which processes can be eliminated or improved, with guidance from the 4M Framework. These teams are using evidence-based practices to enhance quality, efficiency and the patient and family experience. 

At the conclusion of this activity, attendees should be able to:
Analyze the impact COVID-19 has had on transitions and care coordination for older adults
Describe the concepts of an Age-Friendly Health System
List the key initiatives of the "What Matters" program
Recognize the long-term effects to providers, patients, and their family caregivers recovering from the COVID-19 pandemic

Get the Full Course Details and Get Started: HERE

Complimentary for ABQAURP Diplomates and Professional Members November 17, 2022 through December 18, 2022*

View this course and all our online offerings HERE.
*Price will automatically update in your cart to no charge when ordering online. Spotlight course is also available to non-members at regular price. The American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.  ABQAURP designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.  ABQAURP is an approved provider of continuing education for nurses. This activity is designated for 1.0 contact hour through the Florida Board of Nursing, Provider # 50-94. 

Diplomate Focus 

The Anatomy of a Review: Seven Points to Consider Regardless of Payor or Provider Viewpoint
By Hemant Gupta, MD, MSc, CHCQM-PHYADV

You are a physician advisor, or a health plan medical director, and you have been sent a case from a UR nurse who is asking you for your professional opinion on a medical necessity review for a level of care. 

Your choices are to keep the status observation, downgrade to outpatient in a bed, or upgrade it to inpatient. Here are some points to consider: 
1. Consider the insurance plan of the patient. Yes, when making status determinations it is important to discern if the case is for Medicare fee-for-service (FFS) vs non-Medicare FFS. 

2. Consider the attending’s concerns in the documentation and the status they chose and why they chose it. Did the care that was documented seem reasonable and necessary by the practice standards of that hospital, region,  and did it span for two midnights (especially for Medicare FFS)? 

3. How long has the patient been in the hospital? Are they a transfer? When did the episode of care start? (Be aware of the two-midnight clock start in a Medicare FFS case.) 

4. Do not get married into a diagnosis and equate it to a specific status. Have an open mind. Review all the relevant primary information, when possible, prior to making a decision. 

5. Consider using MCG and InterQual guidelines in helping you come to the decision, especially if 48 hours or so have elapsed and the patient still needs hospital level services. Be aware, Medicare FFS does NOT ascribe to commercial criteria for Medicare FFS cases at the secondary review level.

6. What is present at the time of your review and what is NOT present at the time of your review is equally important. 

7. If unsure of status, and it is possible to call the attending, please do! You may be surprised by what you learn. There is a lot that does NOT get documented in the record that is indeed quite important. This is an opportunity to make a relationship and extend gratitude for the hard work of clinical care. Be careful to not guide, direct their care, or give them the idea that it is not medically necessary. It is very important to stay constructive, positive, and leave the door open even if you disagree.

Remember, you are doing a clinical review of a case for a financial payment of care. You are not the attending. Writing a review has several parts. The clinical summary, the diagnosis, and the rationale under which you made your determination are parts of a strong review. 

Painting an accurate picture, utilizing evidence-based medicine guidelines, risk calculators, commercial criteria, the two-midnight rule or its exceptions, and discussing a case for a specific status and against a status are all tips to help improve your argument. 

Try not to repeat the clinical summary in your rationale. Try not to be generic in your statements or create canned text. None of these strengthen your review. If a statement can be used in every case, then it lacks specificity of “why” this patient, “why” now, and “why” this status. 

We are put into a unique situation in these case reviews. No two people are alike, neither are their care pathways or stories. Be specific, it will show you reviewed all the relevant data and made the BEST decision with that data at hand. An audit can come from the state, the federal government, a QIO, RAC/MAC, IRO, an appeals committee, the system level, a hospital, or a courtroom. Make your reviews count, make them legible and professionally written. Time taken early will save time later when you wonder what you were thinking when you recommended a status. Strong reviews are internally consistent and show the use of many angles for a case for a specific status. You will never please all sides. Stick to the medical record, case discussions with the attending, social, safety, standards of care, psych/behavioral, and need for care or for a lack of the need. Remember, medically necessary care is care that is needed and not merely existent, without which the patient would suffer with a poor outcome. 

If the above is new, or you are struggling with these, remember there is training for this kind of thing. You are not alone! 

Federal Register/August 19, 2013/Summary: https://www.federalregister.gov/documents/2013/08/19/2013-18956/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the

CMS Fact Sheet: Two-Midnight Rule: https://www.cms.gov/newsroom/fact-sheets/fact-sheet-two-midnight-rule-0

Livanta QIO: https://www.livantaqio.com/

CMS Oversight of the Two-Midnight Rule for Inpatient Admissions summary: https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000538.asp

RACmonitor “The Nuances of the Two-Midnight Rule”: https://racmonitor.medlearn.com/the-nuances-of-the-two-midnight-rule/

Federal Register/Vol 80, No 219/Friday, November 13, 2015/Rules and Regulations: https://www.govinfo.gov/content/pkg/FR-2015-11-13/pdf/2015-27943.pdf

A Message from our Corporate Member: Sound Physicians 

At Sound Physicians, the Medical Director of Advisory Services is a high-visibility leader within the medical staff. In this role, you are directly responsible for utilization management activities for the hospital partner, serving as a liaison to providers, case management, revenue cycle, and compliance professionals onsite to improve the accuracy of clinical documentation improvement efforts. Additionally, the Medical Director of Advisory Services typically leads, if not chairs, the utilization management committee for the hospital. You’ll use your experience as a front-line clinician, paired with the training provided by Sound Physicians and Sound Physicians’ automated case review process, to own status determinations, allowing hospitalists and case managers to focus on patients. Learn more about our nationwide Physician Advisor opportunities at: careers.soundphysicians.com

CHCQM Digital Credentials! 

Health Care Quality & Management Certification

Issued by American Board of Quality Assurance and Utilization Review Physicians© (ABQAURP)

Earners who have achieved certification in HCQM are deeply committed to patient safety, health care quality, and effective care. Those certified in HCQM demonstrate their superior ability to critically evaluate industry literature, identify evidence-based best practices, and make recommendations that balance appropriateness of health care services with cost and quality. HCQM Board Certification addresses the need for effectiveness, efficiency, equity, safety, and timeliness. 

In October, Diplomates should have received several emails detailing the CHCQM digital credentials from Credly. There is still time to "Accept" your badge to download and utilize your CHCQM and Sub-Specialty digital credentials. 

This electronic representation of your hard-earned credential will be displayed on the Credly website for users to share with colleagues and employers. You can easily share this on your social media platforms like LinkedIn. This program replaces the Diplomate Logo program and eliminates the need for you to apply and submit forms to enable your logo. An invitation to accept your credential is automatically sent to all candidates that successfully complete the HCQM Certification Exam, renew their certification bi-annually, or earn a sub-specialty credential during their membership. 

If you have questions about digital badge use, visit: https://www.abqaurp.org/ABQMain/CHCQM_Badge_Landing.aspx. If you
did not receive your digital badge notice from Credly, please email us at: abqaurp@abqaurp.org.

Diplomates and Members: 2022 Member Referral Program 

ABQAURP Diplomates and Professional Members are eligible to receive a referral bonus when referring new Professional Members and HCQM Exam Candidates. Earn a bonus for each referral and qualify for the $500 Visa gift card for the most referrals, includes a registration for the 2023 Annual Conference to receive your prize! 

View details in the Member’s Only section of the website: www.abqaurp.org/Members_Only.aspx

Is Your Continuing Medical Education Accredited?

ABQAURP welcomes applications for joint providership of educational activities for continuing medical education credit. ABQAURP accredits a variety of activities including live activities, enduring materials, and more.

As an accredited provider, ABQAURP works with each joint provider organization to ensure the accreditation process runs as smoothly as possible. 

For more information, please contact the Education Department at (800) 998-6030 or education@abqaurp.org

Follow ABQAURP on Social Networks

Follow us on social media to keep up to date on our announcements, special incentives on our programs and services, and topical discussions from fellow leaders in the health care arena! Share strategies with your peers to cope in this uncertain time.

ABQAURP LinkedIn Group

ABQAURP Facebook Page