Montana Annual Report of QIO Case Review Information
Wyoming Annual Report of QIO Case Review Information
Hawaii Annual Report of QIO Case Review Information
Alaska Annual Report of QIO Case Review Information
Mountain-Pacific’s role as a quality improvement organization is to protect the rights of Medicare beneficiaries, protect the Medicare Trust Fund and improve quality of care. We review the medical records of beneficiaries who have concerns about the quality of care they receive under Medicare. We implement quality improvement activities to improve an identified quality of care concern. If possible we also offer patients the opportunity to resolve their concerns through alternative forms of dispute resolution, such as mediation.
We also review appeals from beneficiaries or their representatives who feel the beneficiary’s care under Medicare is ending too soon. All of the cases reviewed by Mountain-Pacific must meet one of these objectives. Cases may be reviewed for utilization, quality and correct DRG assignment. Referrals for the different types of reviews come from a variety of sources including Medicare beneficiaries and their families, the Centers for Medicare & Medicaid Services, and fiscal intermediaries.
Quality improvement organizations are also responsible for monitoring physician acknowledgement statements for hospitals. Because hospitals are paid under the prospective payment system based on the physician’s diagnoses, all newly credentialed physicians must sign and have a statement on file prior to their first admission to the hospital or first claim submission.
In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services. They are required to provide an appropriate medical screening examination, within the capacity of the hospital’s emergency department, including ancillary services routinely available to the emergency department. These services must be provided to anyone making a request for examination or treatment for an emergency medical condition, including active labor, regardless of an individual’s ability to pay. Hospitals are then required to provide stabilizing treatment for those patients determined to have an emergency medical condition. If a hospital is unable to stabilize a patient within its capability, or if the patient requests a transfer, an appropriate transfer should be implemented.
CMS-related links can be found by clicking on http://www.cms.gov/EMTALA/01_overview.asp
QIOs are required to perform two reviews for anti-dumping cases.
- Five-day review - The first review, which was an optional five-day medical advisory review, is mandatory. The regional office requests the QIO’s medical expertise on whether the individual was adequately screened, examined and treated. This review assists the regional office in making a compliance determination that would terminate a hospital’s Medicare participation because of EMTALA violations. The QIO is also required to provide a copy of the report on its findings to the hospital or physician, consistent with existing confidentiality requirements.
- 60-day review - The second review is a mandatory 60-day review. The regional office requests a QIO medical review before the Office of the Inspector General can decide on an imposition of a civil monetary penalty or a physician exclusion. Part 9 of the QIO manual addresses QIO anti-dumping reviews in detail: http://www.cms.gov/manuals/downloads/qio110c09.pdf
Higher weighted DRGs
As a quality improvement organization, Mountain-Pacific is required to review hospital requests for higher-weighted DRG assignments as addressed in 42 CFR 412.60 (d)(2) and 476.71 (c)(2). As part of this review, hospitals submit requests for higher-weighted DRG assignment directly to the intermediary for processing and payment. All such requests granted by the intermediary are subsequently selected by CMS for QIO review on a post-payment basis.
Hospitals have up to 60 calendar days after the remittance advice date to request the increase. Medical-necessity review and DRG validation will be performed on all cases submitted to Mountain-Pacific for higher-weighted DRG review. A quality review will also be performed if Mountain-Pacific believes there may be a potential quality-of-care concern.
Quality of care concerns
Quality improvement organizations are required to review all written complaints received from Medicare beneficiaries or their designated representatives about the quality of services received from providers reimbursed by Medicare. This includes hospitals, hospital outpatient areas, skilled nursing facilities, home health agencies and physician offices.
The Beneficiary Complaint Response Program is directed at beneficiaries or their representatives who have a concern or are not satisfied with the care they received under Medicare. Mountain-Pacific recommends to beneficiaries that, before filing a formal complaint, they speak first with their health care provider(s) to see if their concerns might be successfully resolved through direct discussion. If this isn't feasible or if the process fails, a beneficiary or their representative can formally file a complaint. There are several ways to initiate a complaint: via our toll-free helpline, 800-497-8232; with a letter detailing the concerns about care; or using our easy complaint form, which can be filled in, printed off, and mailed (we discourage e-mails as these are not a secure method for sending confidential information.)
Once we receive a complaint, the quality of care review begins. The process usually involves a medical record review using a traditional peer review process. Following the review, if quality or utilization concerns are identified, we provide education and feedback to providers and their medical staff to improve quality or utilization of services delivered to patients.
In cases in which significant quality of care issues are not a concern, alternative forms of dispute resolution are sometimes implemented to resolve beneficiary complaints.
Alternative dispute resolution
Alternative forms of dispute resolutions may sometimes be used to address complaints:
- Mediation is a consensual and collaborative process in which the parties have agreed to mediate in good faith and to authorize a third party, the mediator, to facilitate their efforts to reach a resolution of their conflict. In contrast to arbitration, the parties themselves decide the outcome and create a mutually agreed upon resolution.
- Facilitated resolution is a similar alternative that has been recently implemented. However in these cases the parties do not meet face to face but use a third party who speaks to those involved in separate conversations.
After a complaint is received from a beneficiary, an initial peer physician review is done to detemine whether an individual case might be a candidate for an alternative resolution process. These options are offered in instances where significant quality of care problems are not present and where there appear to be communication issues between the beneficiary and the health care provider.