Purpose of QRT IQRs

6. QRT IQRs

Introduction

This topic contains information about QRT IQRs, including

• purpose of QRT IQRs,
• review criteria for QRT IQRs,
• standard of review for QRT IQRs,
• recording method for QRT IQRs, and
• QRTIQR-FINAL Review Level and QRT coach responsibilities.

Change Date

November 15, 2023

3.A.6.a. Purpose of QRT IQRs

A review of the individual’s work is intended as a performance measure to ascertain the quality element in that individual’s performance standard.

A QRT IQR is intended to provide an evaluation of an individual QRS’s work product to determine if the minimal standard for correctness has been met.

QRT IQRs are the review of five randomly-selected cases per month (on average) for the QRS. These reviews determine employees' individual quality level as part of the overall performance evaluation.

The intent of the performance standard is to obtain an average of five per month over the entire fiscal year for each employee to assess the quality element in the standard.

3.A.6.b. Review Criteria for QRT IQRs

QRSs are responsible for performing IQRs identified by QMS on other QRSs. QRT IQRs, with cited errors, will be routed via QMS to a QRT coach for peer review. These reviews will consist of a random selection of work based on the amount set forth in the national performance standards. The selection of actions, while random, will reflect an appropriate mix of work performed by the employee throughout the month (i.e., not from a single day or single week). However, when a QRS is not working the appropriate mix of work on an ongoing basis to provide a mix of work for the QRS, the selected reviews are to be accepted.

3.A.6.c. Standard of Review for QRT IQRs

The standard of review for QRT IQRs is to ensure accurate completions of the quality checklists used for DRO, RVSR, VSR, and CA IQRs. The QRT IQR will encompass a thorough assessment of the QRS's completed checklist in its entirety to ensure that the minimum standard for review has been met on the initial quality review.

The minimum standard includes proper selection of "Yes," "No," and "NA" on the checklist task questions.

• The minimum standard for review is to ensure all "No" responses on the checklists rise to the level of a clear and unmistakeable error (CUE) or a clear violation of current regulations or directives.
• The minimum standard for review is to ensure all "Yes" responses on the checklists account for the proper actions implicitly or explicitly taken by the DRO, RVSR, VSR, or CA for the transactions(s) under review.
• The minimum standard for review is to ensure all "NA" responses on the checklists do not apply to the transaction(s) under review.
• Selecting the proper checklist responses to reflect the appropriate answer for each task is important to ensure the DRO, RVSR, VSR, or CA receives credit for work completed correctly or ensuring the employee does not receive undue credit for work not applicable to the transaction under review.

A QRS performing a QRT IQR will select either "Agree" or "Disagree" with the initial review performed. If an error is found on the initial review, to include only changing a task question response from "Yes" to "NA" or "NA" to "Yes," the reviewer performing the QRT IQR will identify the task question(s) in error in the comment box along with a complete error narrative.

QRT Performance Errors are required when correcting question responses to reflect the appropriate answer for a task because it is important to ensure DROs, RVSRs, VSRs, and CAs receive credit for work completed correctly or to ensure the employees do not receive undue credit for work not applicable to the transaction(s) under review.

When changing a response to a question, only changes to questions 1 through 11 on the DRO, VSR, and RVSR checklists and the entirety of the CA checklist are considered critical. A change to a non-critical question is not considered a performance error against the QRS.

Important: A performance error is warranted any time the checklist is found to be in error for a critical question. Whether something rises to the level of a benefit entitlement error is irrelevant when conducting and completing IQRs.

Example 1: An RQRS is completing a review on the Rating Decision Complete (RDC) transaction. The previous RQRS marked the review correct. The RQRS conducting the QRT IQR determined that the evaluation for sleep apnea was incorrect because the RVSR did not assign a 50 percent evaluation based upon use of a CPAP. The RQRS will "Disagree" with the initial review and will include the following narrative in the comment box: "Error for incorrect evaluation of sleep apnea. The RQRS failed to cite a Task 7 error on the RVSR."

A coach reviewing this disagreement on a QRTIQRFinal review would indicate that a performance error is appropriate against the RQRS who completed the initial review.

Example 2: An AQRS is completing a review on the claim transaction for generating an award (Award). The previous AQRS marked a Task 9 error because the award did not include a withholding for military retired pay. The AQRS conducting the QRT IQR determined that a withholding was not required. The AQRS will "Disagree" with the initial review and will include the following narrative in the comment box: "No error is present. The AQRS incorrectly cited a Task 9 error on the VSR."

A coach reviewing this disagreement on a QRTIQRFinal review would indicate that a performance error is appropriate against the AQRS who completed the initial review.

3.A.6.d. Recording Method for QRT IQRs

In QMS, an IQR on a QRS is identified as QRTIQR in the Review Level column in the My Reviews view, which can be accessed by clicking on the Review Landing Page tab. You can also identify whether the IQR selected is for a QRS by reviewing the Review Detail screen. If QMS selects an IQR for a QRS, the QRT Performance Review box is checked on the Review Detail screen. To open the review, click on the review name in the Review Name column, which will open the Review Details screen. To see additional information, select the Review Summary button from the Review Detail screen. To begin the review:

• Select the Perform Review button on the Review Detail screen.
• Scroll down to Claim Review – Initial Review Process which will display the recorded review to include any errors cited and error citation box.
• After completing a review of the QRS’s review, scroll down to the Subsequent Reviewer Decision section, which includes the My Comments, Agree and Disagree.
• The reviewer will complete the My Comments box and select either the Agree or Disagree button depending on the outcome of the case. If the reviewer selects Disagree, the reviewer provides the error narrative with the error category from the associated quality review checklist.

Note: A comment is required regardless of whether the Agree or Disagree option is selected. If the reviewer agrees with the QRS’s initial review, the reviewer must input a comment, select the Agree button, and click the Submit button. Once the QRS selects the Submit button, the review is complete. If the reviewer disagrees with the QRS’s initial review, the checklist completed during the initial review will require modification and/or correction. When the Disagree option is selected, the reviewer is returned to the initial review page that contains the Claim Information with the quality marks and comments provided by the initial reviewer. The reviewer will cite any additional errors found and/or correct any of the errors called on the initial review. After correcting the corresponding checklist, the reviewer selects the Review Summary button, noting the error that was cited or should have been cited from the applicable checklist. Once the review checklist is updated and the error narrative is input in the comment box, the reviewer will select the Submit Review button and the review is complete. Reference: Refer to the QMS User Guide for QRT IQR routing rules and procedures.

3.A.6.e. QRT IQR-FINAL Review Level and QRT Coach Responsibilities

QRT IQRs with cited errors will be routed via QMS to a QRT coach for peer review.

All QRT IQRs that result in a Disagree are routed to the QRTIQRFINAL review level. This level is directed to a QRT coach for a determination on the outcome of the review. The coach performs the review using the same steps listed above.

Important: If the coach is agreeing with the changes to the review made by the last individual that reviewed the case, this indicates the QRTIQRFINAL individual is approving the changes and the disagreement indicated by the QRTIQR reviewer. A disagreement at the QRTIQRFINAL level is used if the coach does not agree with the subsequent reviewer’s determination.