By Heather Rutland, J.D., Of Counsel, Garlo Ward P.C.
Posted December 6, 2004
What is the Texas Medical Foundation? What information do I have to give them? What can they do with their information? What information do they have to give to me? These are all important questions for any health care facility, and the following article will give you a general walkthrough of each of these issues.
Issues addressed in this article:
- What is the Texas Medical Foundation?
- What information do I have to give them?
- What about our originals?
- What is off limits?
- What about records and information of institutions and practitioners?
- What about records and information of NON-Medicare patients?
- What about information that is generated or collected specifically for TMF purposes?
- What can they do with their information?
- What about non-confidential information?
- When can TMF disclose information about patients?
- What information must TMF give to CMS?
- What information is transferred within the QIO system?
- What about information related to payment of claims for Medicare?
- What about information related to claims of fraud and abuse?
- Can TMF disclose information for anything else?
- What information do they have to give to me?
What is the Texas Medical Foundation?
The Texas Medical Foundation (TMF) is an organization that has been chartered by the Centers for Medicare & Medicaid Services (CMS) to be the Quality Improvement Organization (QIO) for Texas. Every state has a QIO and the CMS generally defines the purposes of a QIO to be the following:
- to investigate beneficiary complaints about quality of care;
- to safeguard the integrity of the Medicare trust fund by ensuring payment is made only for medically necessary services; and
- to work with consumers, physicians, hospitals and other caregivers to refine care delivery systems to make sure patients get the right care at the right time, particularly among underserved populations.
What information do I have to give them?
What about our originals?
** TMF is not authorized to take originals of any documents. If TMF requests documents that it is entitled to get, BE SURE to make photocopies of those documents to give them and do not give up the originals.
What is off limits?
** It is important to note that Quality Assessment and Assurance Committee (QAAC) information is statutorily protected under the Omnibus Budget Reconciliation Act of 1987. It states:
“A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this subparagraph.”
– the mentioned subparagraph deals only with the requirements for the makeup of the committee, the frequency the committee must meet, and what the general purpose of the committee is.
** It is also important to note that TMF, or any actor on its behalf, CANNOT collect ANY information that is not necessary to accomplish its purposes under its charter with CMS.
What about records and information of institutions and practitioners?
TMF is authorized to have access to records and information that is pertinent to the health care services furnished to Medicare patients. This applies to any information held by any institution or practitioner in the TMF area.
What about records and information of NON-Medicare patients?
If the information and records relate to a review performed under a non-Medicare TMF contract then TMF must have the patient’s authorization.
If the information and records are in accordance with its quality review responsibilities, then TMF must have the authorization of the institution or the practitioner.
What about information that is generated or collected specifically for TMF purposes?
Institutions and other entities that collect information for TMF purposes must disclose that information to TMF. Institutions or practitioners that collect or generate information to carry out a “quality review study” must disclose that information to TMF.
A “quality review study” is an assessment, conducted by OR for TMF, of a patient care problem for the purpose of improving patient care through peer analysis, intervention, resolution of the problem and follow-up.
What can they do with their information?
What about non-confidential information
TMF must disclose to any person, upon request, non-confidential information. Such information includes things like:
- The norms, criteria, and standards it uses for initial screening of cases, and for other review activities;
- Copies of documents describing administrative procedures, agreed to between TMF and institutions or between TMF and the Medicare intermediary or Medicare carrier;
- Routine reports submitted by TMF to CMS to the extent that they do not contain confidential information;
- Public information in its possession;
- Aggregate statistical information that does not implicitly or explicitly identify individual patients, practitioners or reviewers;
- Quality review study information including summaries and conclusions from which the identification of patients, practitioners and institutions has been deleted; and
- Information describing the characteristics of a quality review study, including a study design and methodology.
When can TMF disclose information about patients?
TMF must disclose any patient information in its possession to the identified patient (or the patient’s representative) if:
- the patient or patient representative requests the information in writing, and
- all other patient and practitioner identifiers have been removed.
TMF must release the requested patient information directly to the patient. If such disclosure would harm the patient (as determined by the attending physician or practitioner) then the information must be released to the patient’s representative.
** It bears noting that any patient representative request must also include the patient’s designation of the representative before any information may be released to the representative.
If the patient is mentally, physically or legally unable to designate a representative, TMF must disclose the information to a person whom it decides is responsible for the patient.
What information must TMF give to CMS?
TMF must, in general, disclose all information requested by CMS.
What information is transferred within the QIO system?
TMF must disclose to other QIOs, subcontractors, consultants, medical review boards, and to individuals within the review system, all information necessary to fulfill their duties under the CMS charter.
TMF must also disclose information on patients and practitioners to other QIOs if those patients and practitioners are subject to review by those other QIOs.
What about information related to payment of claims for Medicare?
TMF must disclose information to intermediaries and carriers, if the information relates to or is necessary for, payment of claims. TMF may disclose this information without request.
What about information related to claims of fraud and abuse?
TMF must disclose confidential information relevant to an investigation of fraud or abuse of Medicare or Medicaid programs to Federal or State agencies that are responsible for the investigation. TMF may disclose this information without request
Can TMF disclose information for anything else?
Yes. TMF must disclose information to State and local health officials whenever TMF determines that the disclosure is necessary to protect the public health.
TMF must also disclose information upon request to a State or Federal licensing body that is responsible for the professional licensure of a practitioner or a particular institution.
What information do they have to give to me?
TMF deliberations are not disclosable in connection with a beneficiary’s claim, however, you can request the reasons supporting TMF’s determination. Upon such a request, TMF must then provide you with detailed facts supporting its determination. TMF must first insure that the opinions or judgments of a particular individual or practitioner cannot be identified through the disclosed materials.
TMF deliberations include discussions or communications (within TMF or between TMF and a TMF subcontractor) including review notes, minutes of meetings, and any other record of discussions and judgments involving review matters regarding TMF review responsibilities and appeals from TMF determinations.
TMF must also disclose to you any quality review study information so long as the information is limited to health care services that you furnish.
All information in this article is informational only and is not legal advice. Should you have any questions or a situation requiring advice, please contact an attorney.
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Telephone: 512-302-1103
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Email: Info@Garloward.com
