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Event Information and Resources Presciption Pain Medication Project (PPMP) |
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Case Review
HealthInsight is responsible for the review of healthcare services provided to Medicare beneficiaries to determine if these
services meet medically acceptable standards of care, are medically
necessary, and are delivered in the most appropriate setting.
HealthInsight is also required to perform Diagnostic Related Group (DRG) validation
on all cases selected for review to ensure that the diagnostic and
procedural codes reported by the provider and resulting in DRG assignment
by the Fiscal Intermediary (FI) match both the documentation in the
medical record and the physician's attestation.
Why does such a program exist?
- To provide proactive awareness, education, and practical
solutions for hospitals.
- To reduce the amount of Medicare dollars
paid in error for fee-for-service beneficiaries in Nevada and Utah.
- To ensure solvency within the national Medicare Program.
Chart Review Methodology:
- A national random sample of medical charts is requested by the Clinical
Data Abstraction Centers (CDACs) monthly in each state.
- Any medical
record failing initial screening by CDAC is forwarded to HealthInsight for a mandatory full-case review.
- An additional 10 percent of the charts
are blinded and included in the sample for HealthInsight.
- Full
case review is done on all higher weighted DRGs submitted by the facilities.
- HealthInsight is required to submit any case failing non-physician review to a peer-level physician review for final determination.
Questions?
Contact qaops@healthinsight.org
