Medicare Review Programs Flashcards

Questions and Answers

What is the purpose of the review done as specified in section 1862(a)(1)(A) of the Social Security Act?

To ensure billed items are covered

To ensure billed items are necessary

To ensure billed items are reasonable

All of the above (correct)

What do QIOs focus on?

Improving quality of care for beneficiaries and protecting the integrity of the Medicare Trust Fund.

QIOs can review beneficiary appeals in response to provider-based notices.

True

What are the two types of QIO organizations that can exist in a state or region?

Beneficiary and Family-Centered Care (BFCC) QIOs and Quality Innovation Network (QIN) QIOs. Signup and view all the answers

CMS established a website called ______ to provide healthcare quality improvement resources.

QualityNet Signup and view all the answers

What are Medicare Administrative Contractors (MACs) responsible for?

Processing medical claims for Medicare beneficiaries Signup and view all the answers

Study Notes

Medicare Review Programs

Medicare review programs ensure billed services align with coverage and necessity as outlined in section 1862(a)(1)(A) of the Social Security Act.
The Centers for Medicare & Medicaid Services (CMS) performs reviews on acute Inpatient Prospective Payment System (IPPS) and long-term care hospital (LTCH) records for payment validation.

Quality Improvement Organizations (QIO)

QIOs are not-for-profit organizations focused on enhancing care for Medicare recipients, comprising health quality experts, clinicians, and consumers.
They aim to improve healthcare quality by collaborating with providers through various quality improvement efforts.

QIO Functions

QIOs concentrate on the following areas:
- Enhancing the quality of care for Medicare beneficiaries.
- Safeguarding the integrity of the Medicare Trust Fund by ensuring payment only for reasonable and necessary services provided appropriately.
- Reviewing beneficiary appeals related to provider-based notices.
- Investigating allegations concerning the Emergency Medical Treatment and Labor Act (EMTALA) violations.

Changes in QIO Structure

CMS modified rules to allow multiple QIO entities within a state or region.
Two types of QIO organizations now exist:
- Beneficiary and Family-Centered Care (BFCC) QIOs manage beneficiary complaints and quality of care evaluations.

Quality Innovation Network (QIN) QIOs

The second type, Quality Innovation Network (QIN) QIOs, collaborates with healthcare providers on data-driven projects directed at enhancing patient safety and clinical care at the community level.

Medicare Claims Processing

CMS has partnered with private insurance companies to handle medical claims for Medicare beneficiaries, previously known as Part A Fiscal Intermediaries (FI) and Part B carriers.
Following the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, CMS replaced Part A FIs and Part B carriers with Medicare Administrative Contractors (MACs).

Medicare Administrative Contractors (MACs)

MACs are awarded contracts for Medicare claims processing via a competitive bidding process, substituting former fiscal intermediaries and carriers.

Description

Test your knowledge on Medicare review programs with these flashcards from Chapter 25. Learn about coverage, necessity, and the role of Quality Improvement Organizations in healthcare. Perfect for those studying healthcare policies and regulations.