Medicare Case Review
Mandatory case review continues to contribute to improved quality of care for Missouri’s Medicare beneficiaries. Whenever specific requests or referrals are made, our review team of healthcare professionals conducts quality or utilization determinations on individual cases. Such review allows us to provide oversight on medical necessity, appropriateness and quality of care delivered to Medicare patients.
Medical review is conducted on cases brought to our attention by beneficiaries, public inquiries, state and federal agencies and other governmental/congressional referrals. Other areas of review include: hospital issued notices to patients of non-coverage (HINNs); managed care issued notices of non-coverage; and fiscal intermediary or carrier referrals.
Current federal regulations continue to mandate Consolidated Omnibus Budget Reconciliation Act (COBRA) and Emergency Medical Treatment and Active Labor Act (EMTALA) reviews. Additionally, all cases in which a hospital requests reassignment of a claim to a higher-weighted diagnosis-related group (DRG) are examined. These cases receive detailed evaluation by nurses and coding specialists with subsequent physician analysis of those cases identified as having potential quality, utilization or coding (DRG assignment) issues.
Medicare beneficiaries may feel unsure about the quality of medical care they received. Medical terminology and processes can be confusing or they may want to avoid direct confrontation with their physician or provider. Primaris protects beneficiaries by serving as an impartial third-party to evaluate their concerns. In many instances, we find that the beneficiary's concern is based on lack of knowledge or information due to poor communication between physician/ provider and beneficiary. In other cases, the beneficiary's concern is outside the scope of our work and must be referred to another agency, such as the Missouri Board of Healing Arts or the Department of Health and Senior Services.
When a complaint is received, we conduct a complete case review of all the medical care provided to the beneficiary in all settings. After the review is complete, we advise the beneficiary, or representative, our determination as to whether or not the care provided met professionally recognized standards of healthcare. If an instance (or a pattern) of substandard or unnecessary medical care is identified, we work with the facility or physician in question to initiate a plan to correct the questionable practice. Although the reviewed care has already been provided to the beneficiary, that beneficiary and all others will receive better medical care from the facility or physician in the future because of the review and the corrective action taken to improve the practice pattern.
Beneficiaries who are concerned about the quality of care they have received may contact Primaris' Medicare helpline at (800) 347-1016 Monday through Friday from 8:30 a.m. through 5 p.m. Trained staff are able to address concerns related to quality of care. Or, a beneficiary complaint form can be completed and returned. Once this form is received, we will proceed with a complete review. The completed forms should be sent to:
Before termination of Medicare-covered services, the provider (Comprehensive Outpatient Rehabilitation Facilities (CORF), home health agency (HHA), hospice, or skilled nursing facility (SNF)) must deliver valid written notice to the beneficiary of the provider's decision to terminate services. The provider must use a standardized notice as specified by CMS. The provider must also notify the beneficiary of the decision to terminate covered services no later than two days before the proposed end of the services. If, in a non-residential setting, the span of time between services exceeds two days, the notice must be given no later than the next to last time services are furnished.
A beneficiary has a right to an expedited determination by Primaris when he/she disagrees with the provider and/or physicians that services should be terminated. A beneficiary who wishes to exercise the right to an expedited determination must submit a request for a determination to Primaris by midnight of the day of discharge. The beneficiary may submit evidence to be considered by Primaris in making their decision. Medicare coverage of services continues through the appeal process.
Higher-Weighted DRG Adjustments
The payment a facility receives for treating a Medicare patient is based on the provider’s selection of codes for the principal diagnosis, principal procedure, and pertinent secondary diagnosis or procedure codes. Because a Medicare patient often has a number of medical conditions (which may or may not be interrelated) and because of the intricacies of the coding systems, errors are common in these selections. Facilities may resubmit their claims to correct the errors they identify.
When a facility submits a corrected claim to the Medicare fiscal intermediary, which would result in an increased payment to the facility, Primaris must confirm the diagnosis, procedure, and coding assignments to assure that they are substantiated by the medical record. If the adjustment to the claim is substantiated, Primaris will notify the Medicare fiscal intermediary to adjust the DRG payment to the facility accordingly. If the claim adjustment is not substantiated, no payment adjustment is made.
CMS coordinates with a large network of government agencies and contractors, each overseeing a different aspect of the care provided to Medicare beneficiaries. In regard to beneficiary protection in Missouri, Primaris specializes in utilization (medical necessity) and quality review. During the course of its work, a government agency or a Medicare contractor may identify a case in which there appears to be questionable medical necessity or quality of care. In this event, the agency or contractor will refer the case to Primaris for review. In some instances, we also receive referrals to evaluate a possible event or pattern of fraud, waste, or abuse. Referrals are received from CMS (central and regional offices), Office of the Inspector General, Department of Justice, fiscal intermediaries, Medicare Integrity Program, Program Safeguard Contractors, Rural Home Health Intermediaries, M+C Plans, CDACs and others.
Primaris reviews all case referrals (not just Medicare) in which the care provided represents a potential violation of federal anti-dumping provisions. The Emergency Medical Treatment and Active Labor Act (EMTALA) states that if any one comes to the emergency room and requests examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination and necessary stabilizing treatment. Transfer of the person is restricted until they are stabilized. In an anti-dumping case, a hospital's emergency department violates its obligation to examine and treat a patient for an emergency medical condition or a patient in active labor, often by transferring the patient without providing an appropriate medical screening examination or necessary stabilizing treatment. When such cases are referred to Primaris by CMS or the OIG, we must review the alleged violations and provide a report on our findings to the referring source. Reference 42CFR 489.24 at www.gpoaccess.gov for more information.
Assistants at Cataract Surgery
Although any invasive procedure carries risk, cataract surgery is a common procedure with a low rate of complications. Few cases require an assistant during cataract surgery, unless there are complicating medical factors. CMS requires that Primaris review each Missouri ophthalmologist's request for an assistant during cataract surgery. Pre-certification requests should be made to:
Clinical Review Contacts
For further information about individual case review, please contact Rita Ketterlin, Medicare Beneficiary Protection Program, at (800) 735-6776, Ext 153.
If you are a provider wanting information about HINNs or NODMARs, call Missouri's provider helpline at (800) 735-6776, Ext. 153.
If you are a Medicare beneficiary, or are representing a beneficiary, with concerns about the quality of medical care received, hospital-issued notices of noncoverage (HINN) or Notices of Discharge and Medicare Appeal Rights (NODMAR), please call our beneficiary help line at (800) 347-1016.