Medicare case review
As Oregon’s Medicare Quality Improvement Organization (QIO), Acumentra Health participates in the Medicare Beneficiary Protection Program (MBPP) to help protect the safety and health of Medicare beneficiaries.
Required activities under the program include
Responding to beneficiary quality-of-care complaints
Reviewing notices of Medicare noncoverage
Providing information and resources for hospital QIO Liaisons
Providing information and resources for physician reviewers
Beneficiary complaints
If a Medicare beneficiary (including fee-for-service beneficiaries and Medicare Advantage enrollees) or representative has a concern about the quality of care, especially if the beneficiary feels the care was not adequate or appropriate, the beneficiary may contact Acumentra Health and initiate a complaint. Acumentra Health reviews all written quality-of-care complaints from Medicare beneficiaries or their designated representatives.
More information about Medicare Beneficiary rights is available in our beneficiary section, or in the Medicare & You publication on the Medicare website at www.medicare.gov/Publications/Pubs/pdf/10050.pdf.
Hospital QIO Liaisons may download our flow chart about the beneficiary complaint review process.
Review of notices of Medicare noncoverage
The purpose of the Acumentra Health review is to ensure that the notice is correct, and that beneficiaries or managed care enrollees are not discharged prematurely from care or have services discontinued prematurely. A board-certified or board-eligible physician makes the review determinations.
Hospital discharge appeal notices
Effective July 2, 2007, CMS implemented new forms and processes for beneficiary notices related to discharge and QIO review, replacing NODMAR processes for managed care members and continued-stay Hospital-Issued Notice of Noncoverage (HINN) processes for beneficiaries with Original (fee-for-service) Medicare.
More about hospital discharge appeal notices
Notice of noncoverage—Original Medicare (BIPA appeals)
When a skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), hospice, or a hospital providing swing bed services issues a Notice of Medicare Provider Non-Coverage to a beneficiary with Original Medicare, the beneficiary or representative may request an “expedited appeal.” A healthcare provider may also appeal on behalf of a beneficiary.
Notice of noncoverage—managed care (Grijalva appeals)
When a Medicare Advantage plan issues a Notice of Medicare Non-Coverage for care in a SNF or a CORF, or by a home health agency, a Medicare beneficiary or representative may request a “fast-track appeal.” A healthcare provider may also appeal on behalf of a beneficiary.
Resources for hospital QIO Liaisons
Hospital QIO Liaisons are the link between Oregon hospitals and Acumentra Health. We offer resources to support the QIO Liaisons in their role in our website section for QIO Liaisons. A username and password are required to access some items in this section. Contact Acumentra Health if you need to acquire a username and password.
Physician review of medical records
Physician reviewers conduct medical record review to determine whether the care received was medically necessary and appropriate. Reviews may include utilization, coding, or quality of care issues. The reviewer is generally from the same specialty as the physician that provided the care in question. This peer review is an important component of the quality-of-care oversight provided by Medicare quality improvement organizations and external quality review organizations such as Acumentra Health.
If you are interested in becoming a physician reviewer for Acumentra Health, review the qualifications and complete an application.
Resources for physician reviewers
We offer resources to support physician reviewers in their role in our website section for Acumentra Health physician reviewers. A username and password are required to access this section. If you are physician reviewer and you did not receive a username and password, contact Acumentra Health.