To ensure that it can better monitor how its medical staff and contractors adhere to the informed consent requirements of Title 22, sections 70707.1 through 70707.7, the Receiver's Office should develop a plan by August 2014 to implement a process by December 2014 that would include periodically reviewing, on a consistent basis, a sample of cases in which inmates received treatment resulting in sterilization at general acute care hospitals, to ensure that all informed consent requirements were satisfied.
Utilization Management (UM), as part of its committee approval process is conducting prospective reviews to assure proper consent is obtained for all cases where sterilization may occur.
A monthly audit is conducted to assure that all claims with applicable CPT codes are flagged by CCHCS' Third Party Administrator and sent to UM for retrospective review. This review of claims is to verify that approved procedures were performed after at least 30 days and no greater than 180 days from the date the informed consent was signed, consent was signed by operating surgeon/provider and the proper reviews and approvals were given. (See Attachment #5)
*It should be noted that since July 2014 the above review process has been ongoing.
Proposed Action Plan:
Identify and flag Current Procedural Terminology codes that are for services that may directly or indirectly result in sterilization.
The Healthcare Invoice, Data and Provider Services Branch has flagged cases from paid claims with all Current Procedural Terminology (CPT) codes that are for services that may directly or indirectly result in sterilization. These cases are then referred to the Utilization Management for review.
This recommendation is focused on the Receiver's Office periodically ensuring that all informed consent requirements are satisfied. However, the Receiver's Office did not provide evidence demonstrating what its Utilization Management review consists of and that the review addresses the required elements of informed consent.
Agency responses received are posted verbatim.