mcg irr case study answers 2021

Inter-Rater Reliability Testing For Utilization Management Staff

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Introduction

Recent regulatory pressures and certification requirements have heightened the need for payer organizations to abide by specific standards regarding medical management operations. Payer organizations that are making medical-necessity determinations regarding reimbursement for health care services, as well as risk-bearing provider groups to whom some of these functions have been delegated, must insure consistency and appropriateness in their determinations. The most powerful accreditation body for health care payers, the National Committee for Quality Assurance (NCQA), requires that payer organizations carry out periodic inter-rater reliability assessments to insure consistency in medical management decision making.

An inter-rater reliability assessment or study is a performance-measurement tool involving a comparison of responses for a control group (i.e., the “raters”) with a standard. Inter-rater reliability (also called inter-observer reliability) traditionally refers to how well two or more raters agree and is derived from the correlation of different raters’ judgments. For the purposes of this paper, inter-rater reliability is a measurement of how well raters agree with a standard, which is more of an assessment of the validity of the responses. The purpose of the study is to determine whether the raters have been consistently trained and are applying that training in a consistent fashion. The analysis is intended to gauge the raters’ observations and reactions resulting from a specific situation. The principles discussed herein would apply to any set of utilization management guidelines.

An inter-rater reliability assessment can be used to measure the level of consistency among a plan or provider group’s utilization management staff and adherence to organizational medical management criteria or standards. Reasons for conducting an inter-rater reliability study within an organization include:

• Minimizing variation in the application of clinical guidelines;
• Evaluating staff’s ability to identify potentially avoidable utilization;
• Evaluating staff’s ability to identify quality-of-care issues;
• Targeting specific areas most in need of improvement;
• Targeting staff needing additional training; and
• Avoiding litigation due to inconsistently applied guidelines.

NCQA requires that health plans develop and implement an inter-rater reliability process for Health Plan Employer Data and Information Set (HEDIS) compliance. NCQA is an independent review organization dedicated to evaluating and reporting on the quality of managed care organizations. HEDIS is a set of standardized performance measures developed by NCQA with assistance from managed care organizations and employers concerned with quality health care. The performance indicators in HEDIS are continually developing, but most involve measuring access to care, health plan service, provider qualifications, activities that assist people to recover from illness, and management of chronic illness. The combination of these measures is intended to provide a tool for performance comparison of different health plans.

An inter-rater reliability study can provide measurement of many of these quality indicators. It can most readily be used to measure access, as NCQA looks for “fair and consistent health plan decisions about medical treatments and services provided to plan members.” It also can be used to measure service, as NCQA looks for “actual improvements that the plan has made in care and service” (“What NCQA Looks for in a Health Plan,” «http://www.ncqa.org»). This latter indicator can be measured by reviewing the results of the inter-rater reliability study from year to year.

An inter-rater reliability assessment can be a useful tool for a health plan or provider organization. However, as with any benchmarking exercise, it cannot in and of itself enhance performance. To improve outcomes, the assessment must be followed up by analysis of the results and, most importantly, by action.

Medical management clinical guidelines, whether developed internally or purchased and then adjusted to meet specified objectives and local practice standards, are an extension of the organization’s overall philosophies and goals. It is essential to the future viability of the plan or provider organization, the welfare of members and corporate partners, and the organization’s standing in the community that they be applied appropriately and in a uniform fashion. Periodic benchmarking of clinical guideline application via an inter-rater reliability study is one way for an organization to insure its intentions for utilization management are met.

This paper will examine several elements that health plans or provider groups with utilization management responsibilities should consider when designing and implementing an inter-rater reliability study. The example presented illustrates some aspects of the process. The example, although fairly simple, demonstrates how easily an inter-rater reliability study can be performed. However, inter-rater reliability is a complex concept, and a much more detailed analysis is possible. End users of any inter-rater reliability analysis should be advised of the method and depth of the analysis to avoid confusion or misunderstandings.

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Paul Lendner ist ein praktizierender Experte im Bereich Gesundheit, Medizin und Fitness. Er schreibt bereits seit über 5 Jahren für das Managed Care Mag. Mit seinen Artikeln, die einen einzigartigen Expertenstatus nachweisen, liefert er unseren Lesern nicht nur Mehrwert, sondern auch Hilfestellung bei ihren Problemen.

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On-demand informed webinar series, how loma linda university health uses irr to reduce denials.

Please note : This webinar does not offer continuing education credit. 

In this webinar, you'll hear how Loma Linda University Health uses Interrater Reliability (IRR) , a module inside the MCG Learning Management System (LMS), to evaluate, test, and develop staff skills for proper guideline use. By integrating denial prevention strategies tied to proper guideline use, Loma Linda has significantly reduced denials. Learn practical tips for using IRR, as well as how to optimize the use of MCG’s LMS to provide a comprehensive training program and develop staff competencies.

Highlights include:

• How IRR is used to evaluate proper guideline use
• How IRR can be set up to target the most-denied types of cases
• How the LMS can be set up to personalize targeted improvement plans for staff
• Ideas you can apply for successfully delivering education to staff

WHO SHOULD VIEW THIS WEBINAR

Directors, managers, staff and physician advisors involved in case management, utilization management, clinical quality and improvement, nursing, denials management, medical informatics, and more will benefit from viewing this webinar.

OTHER WEBINARS

Please visit our Webinars  page to see more MCG webinars.

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Mcg 27th edition ambulatory care interrater reliability.

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Activity description

MCG (formerly referred to as Milliman Care Guidelines) is a tool that is used to help clinicians complete case reviews and make clinical decisions. The MCG 27th Edition Interrater Reliability (IRR) consists of scenarios that allow users to demonstrate their ability to use the tool correctly by applying the most appropriate ambulatory care evidence-based guideline to each case review.

Course last reviewed: 3/31/2023

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Hardware/Software Requirements Please ensure you are using the web-browser Chrome and disable any pop-up blocking software. Click  here  for information on how to enable pop-ups.

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This activity is designed to meet the educational needs of nurses, physicians and pharmacists.

Learning Objectives

At the end of this educational activity, participants should be able to:

• Analyze ambulatory care scenarios, and
• Identify and apply the most appropriate 27th Edition Ambulatory Care evidence-based guideline to inform care decisions.
• 0.50 ACPE - Pharmacists
• 0.50 AMA - Physicians
• 0.50 ANCC - Nurses
• 0.50 Attendance - General Attendance

Faculty/Planners Rebecca Gleason, RN, CCM Clinical Planner OptumHealth Education

Katherine Dittmer BSN, RN Associate Director Clinical Adherence and Remediation Clinical Consistency and Safety Clinical Performance Optum

Jennifer Every BSN, RN, CCM Training Consultant   Clinical Adherence and Remediation  Clinical Consistency and Safety  Clinical Performance  Optum

Katie Shelton MSN, RN, CCM  Training Consultant   Clinical Adherence and Remediation  Clinical Consistency and Safety  Clinical Performance  Optum

Brian J Kennedy, MD MBA Senior Medical Director Clinical Performance Optum

Disclosures of relevant financial relationships In accordance with the Accreditation Council for Continuing Medical Education's (ACCME) Standards for Integrity and Independence in Accredited Continuing Education, Optum Health Education (OHE) requires all those in control of educational content to disclose their financial relationships with ineligible companies within the prior 24 months. Ineligible companies are defined by the ACCME as companies whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by or on patients. Individuals must disclose all financial relationships, regardless of the amount, with ineligible companies and regardless of their view of the relevance of the relationship to the education. OHE ensures that the content is independent of commercial bias.

The activity faculty/planners have no financial relationships to disclose.

Method for calculating CE credit CE credit was calculated by the complexity of content.

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Nurses The participant will be awarded up to 0.50 contact hour(s) of credit for attendance and completion of supplemental materials.

Nurse practitioners The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts credit from organizations accredited by the ACCME and ANCC.

Pharmacists/Pharmacy technicians This activity is approved for 0.50 contact hours ([0.05] CEU) in states that recognize ACPE. Attending the full program will earn 0.50 contact hours. Unique Activity Number(s): JA0007123-9999-23-078-H01-P

Physicians Optum Health Education designates this enduring activity for a maximum of 0.50  AMA PRA Category 1 Credit ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

PAs The American Academy of Physician Assistants (AAPA) accepts credit from organizations accredited by the ACCME.

Attendance A certificate of attendance will be provided to learners upon completion of activity requirements, enabling participants to register with licensing boards or associations that have not been pre-approved for credits. To apply for credit types not listed above, participants should use the procedure established by the specific organization with which they wish to obtain credit.

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The Internal Rate of Return

The internal rate of return is the discount rate that sets the present value of all cash inflows of a project equal to the present value of all cash outflows of the same project. In other words, it is the effective rate of return that makes a project have a net present value of zero. Thus:

NPV = 0 if r = IRR, for any given project.

PV outgo = PV income when r = IRR

The internal rate of return method of project appraisal assumes that all proceeds from the project can be re-invested immediately, and in projects offering returns equal to the IRR, until maturity. A higher IRR indicates a more “profitable” project.

Interpreting the Internal rate of Return

You should note that the IRR need not be positive – It can be zero or even negative. A positive return indicates that the project makes money for the investor. A zero return indicates that the investor is neither profitable nor loss-making. Lastly, if the IRR is negative, the investor loses money. However, if the IRR is less than -1, it means the yield or rather the return is undefined.

The internal rate of return is usually compared to the cost of capital, usually the weighted average cost of capital, WACC. A project whose IRR is above its WACC increases the shareholders’ wealth. Otherwise, it would be unwise to borrow cash at an interest rate, say, 10% and then invest the money in a project with a rate of return less than 10%. The borrower would be unable to service the loan.

Usually, candidates cannot solve questions involving IRR directly and you may need to carry out linear extrapolation. Working with a spreadsheet or calculator is also a better, easier approach. However, you should aim to understand the manual approach first. It will then be easier to use a calculator.

Question Suppose we have a project with the following cash flows; Outgo: $150,000 at t = 0, $250,000 at t = 1, and some more $250,000 at t = 2 Income: $1 million at t = 3 Find the IRR of the project. A. 25.2% B. 0% C. 23% Solution The correct answer is A. We need to find the rate r such that: $$ -150,000 – 250,000(1 + r)^{-1} – 250,000(1 + r)^{-2} + 1000,000( 1 + r )^{-3} = 0 $$ $$ \text{At } 20\%, -150,000 – 250,000 * 1.2^{-1} – 250,000 * 1.2^{-2} + 1000,000 * 1.2^{-3} = 46,800 $$ $$ \text{At } 25\%, -150,000 – 250,000 * 1.2^{-1} – 250,000 * 1.2^{-2} + 1000,000 * 1.2^{-3} = 2,000 $$ We can approximate r by linear extrapolation using the two values: $$ r = 20\% + \cfrac {(0 – 46,800)}{(2 – 46,800)} * (25\% – 20\%) = 25.2\%$$ Suppose the WACC is 20% in the example above. What would be your advice to investors? Since WACC (20%) is less than IRR (25.2%), the project is economically viable and would increase the investors’ wealth. Conclusion : A capital project should be accepted if its IRR is greater than the cost of capital.

Reading 7 LOS 7a (Part 2)

Calculate and interpret the net present value (NPV) and the internal rate of return (IRR) of an investment.

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