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Medicare Case Review

HealthInsight, as the Quality Improvement Organization (QIO) for Nevada and Utah, participates in the Medicare Beneficiary Protection Program to help protect the safety and health of Medicare beneficiaries and the integrity of the Medicare Trust Fund. HealthInsight may review cases for quality of care, appropriateness of discharge, proper utilization and correct DRG assignment. Referrals for review come from a variety of sources including beneficiaries, Centers for Medicare & Medicaid Services (CMS), fiscal intermediaries, managed care organizations and many others. At HealthInsight, medical professionals perform medical record reviews. Cases submitted to physician review for determination are conducted by reviewers with qualifications to practice medicine; an active license to practice and good standing in the community; and are certified by the American Board of Medical Specialties. HealthInsight performs numerous case review activities related to patient care as part of the beneficiary protection program, including:

Responding to beneficiary quality of care complaints
Reviewing appeals of notices of Medicare non-coverage
Reviewing hospital requests higher weighted diagnosis-related groups (DRGs)
Running other types of case review activity as required

Quality of Care Concerns and Complaints

At the request of the beneficiary or their representative, HealthInsight may review complaints about quality of care, inappropriate setting, utilization of services and other issues. When concerns are identified, the provider is given an opportunity to respond. Determinations are made based on the response received and the documentation in the medical record. Providers may request an appeal or a re-review of a determination, as applicable, based on the type of concern confirmed.

For additional information regarding the Beneficiary Complaint Program:
http://www.cms.gov/BeneComplaintRespProg/01_Overview.asp

Hospital Discharge Reviews and Notice of Medicare
Non-Coverage Appeals

1. Hospital Issued Notices of Non-Coverage (HINNs):
This review is done at the request of the hospital or beneficiary/representative when the hospital has determined that the care the patient is receiving or is about to receive will not be covered. The case is reviewed by a HealthInsight case reviewer with referral to a physician for a determination as to whether the hospital appropriately issued the notice of non-coverage.

HealthInsight no longer performs any retrospective reviews of Hospital-Issued Notices of Non-Coverage. This activity has been discontinued by the Centers for Medicare & Medicaid Services (CMS).
For more information regarding Hospital Issued Notices visit CMS website at: http://www.cms.gov/BNI/12_HospitalDischargeAppealNotices.asp

2. Medicare Advantage (MA) Appeals-SNF/Home Health/CORF:
As of January 1, 2004, enrollees of Medicare Advantage (MA) plans have the right to an expedited review by a Quality Improvement Organization (QIO) when they disagree with their MA plan’s decision that Medicare coverage of their services from a skilled nursing facility (SNF), home health agency (HHA), or comprehensive outpatient rehabilitation facility (CORF) should end. Under the Medicare Advantage program, HHA, SNF, and CORF are required to provide a Generic Notice to alert them that Medicare covered item(s) and/or service(s) are ending and give enrollees the opportunity to request an expedited determination from a QIO.

Medicare Advantage (MA) Notices of Non-Coverage at:
http://www.cms.gov/BNI/09_MAEDNotices.asp

3. Fee-for-Service Appeals-SNF/Home Health/Hospice/Swing Beds/CORF:
The Benefits Improvement and Protection Act (BIPA) of 2000 provides Medicare beneficiaries enrolled in traditional fee-for-service Medicare the right to an expedited appeal of a termination notice of skilled services provided by skilled nursing facilities, home health agencies, hospices, swing bed providers or comprehensive outpatient rehabilitation facilities. These new appeals started July 1, 2005.

Fee-for Service Notices of Non-Coverage at:
http://www.cms.gov/BNI/06_FFSEDNotices.asp

Hospital Requests Higher Weighted Diagnosis-Related Groups (DRGs)

Medical records are reviewed by case reviewers at the request of the hospital for a higher weighted DRG. Upon receipt of the record, the documentation is reviewed for compliant coding, diagnostic grouping and any other potential issues.

Quality Improvement Activity (QIAs)

Other Mandated Review Activity

Emergency Medical Treatment and Active Labor Act (EMTALA): EMTALA cases are referred to HealthInsight by the Centers for Medicare & Medicaid Services (CMS) for assessment. Reviews are conducted to determination if an individual had an emergency medical condition that had not been treated or had not been stabilized before being transferred. For More information visit CMS web page: http://www.cms.gov/EMTALA/