Medicare case review

Fact sheet on Medicare QIOs and Beneficiary Protection (PDF* from Centers for Medicare & Medicaid Services)

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 and the integrity of the Medicare Trust Fund.

Required activities under the program include

Beneficiary complaints

If a Medicare beneficiary (including fee-for-service beneficiaries and Medicare Advantage enrollees) or representative has a concern about the clinical 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.

Download a flow sheet about the beneficiary complaint review process (PDF)

Alternative dispute resolution

If Acumentra Health reviewers do not identify significant quality-of-care concerns but see a possible miscommunication or misperception regarding medical care, a case may be recommended for mediation or another form of alternative dispute resolution.

More about alternative dispute resolution for beneficiary complaints

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. An actively practicing, board-certified physician makes the review determinations.

Hospital discharge appeal notices

In July 2007, CMS revised the process for beneficiary notices related to discharge and QIO review. The Important Message from Medicare notice and process replaced the Notice of Discharge and Medicare Appeal Rights (NODMAR) process for managed care members and the continued-stay Hospital-Issued Notice of Noncoverage (HINN) process for beneficiaries with Original (fee-for-service) Medicare.

More about hospital discharge appeal notices

HINNs that remain in effect

Notice of noncoverage—Original Medicare (BIPA appeal)

When a skilled nursing facility (SNF), 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.

More about BIPA appeals

Notice of noncoverage—managed care (Grijalva appeal)

When a Medicare Advantage plan issues a Notice of Medicare Non-Coverage for care in a SNF 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.

More about Grijalva appeals

Requests for higher-weighted DRGs

When a hospital requests a higher Diagnosis-Related Group (DRG) payment from Medicare, Acumentra Health is required to perform a full case review.

More about full case review for DRG requests

Resources for QIO Hospital Liaisons

QIO Hospital Liaisons are the link between Oregon hospitals and Acumentra Health.

View QIO Hospital Liaison resource page

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.

Acumentra Health welcomes new physician reviewers in all specialities.

View qualifications for physician reviewers

Request an application packet

Resources for reviewers

Last updated August 17, 2011