HealthInsight : : Beneficiary Protection Plan

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

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.hhs.gov/BeneComplaintRespProg/01_Overview.asp

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.hhs.gov/BNI/12_HospitalDischargeAppealNotices.asp
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.hhs.gov/BNI/09_MAEDNotices.asp
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.hhs.gov/BNI/06_FFSEDNotices.asp

Click here to view an overview of the expedited determination process.

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.hhs.gov/EMTALA/

Long-Term Care Hospitals: Long-term care hospitals are defined as hospitals that have an average Medicare inpatient length of stay greater than 25 days. These facilities usually provide extended medical and rehabilitative care for patients who are clinically complex and may suffer from multiple and/or chronic conditions.

Resources / Links
Medlearn Matters. Part of the Medicare Learning Network, this searchable database contains articles needed to explain and support CMS transmittals.

Medicare Regulations and Guidance
This page contains many useful resources and references.

Office of Inspector General—Department of Health and Human Servces Workplan. Describes OIG work activities, organization and work planning process for FY 2009 in order to promote economy, efficiency, and effectiveness in the administration of the Department of Health and Human Services’ program offerings. (115-page PDF)

Noridian Administrative Services– Medicare Administrative Contractor. Site offers news, publications forms and training as well as information on claim submissions, appeals and audit activities.

Medicare Internet Only Manuals. Find the Medicare Claims Processing Manual and other publications among the Internet-only manuals, which are replicas of the Agency's official record copy. They are CMS' program issuances, day-to-day operating instructions, policies, and procedures that are based on statutes, regulations, guidelines, models, and directives.

Medicare Managed Care Manual. This manual provides more information about managed care notices and processes for appeals. At the end of the manual, in Appendix 7, the NOMNC and DENC are available in PDF format. (96-page PDF)

Palmetto GBA: Partners in Excellence. Palmetto GBA administers Medicare health insurance for the Centers for Medicare & Medicaid Services (CMS). We have been a Medicare contractor since the inception of the program in 1966 and provide service throughout the United States and its territories. Palmetto GBA is a wholly owned subsidiary of BlueCross BlueShield of South Carolina and is based in Columbia, South Carolina.