Case Review
Overview of IFMC Medicare Case Review Activities
Mandatory case review contributes to improved quality of care for Medicare
consumers in Iowa. Whenever specific requests or referrals are made, our
review team of health care professionals conducts quality, utilization and
coding determinations on individual cases. Such review allows us to
provide oversight on medical necessity, appropriateness and quality of
care delivered to Medicare patients.
IFMC continues to oversee the medical necessity, appropriateness and
quality of Medicare services through case review in these specific
categories:
Anti-dumping review (Emergency Medical Treatment & Active Labor Act - EMTALA)
Higher-weighted Diagnosis Related Group (DRG) adjustment review
Hospital-Issued Notices of Noncoverage (HINN) review
Hospital Discharge Appeals
Consumer complaint review/Alternative Dispute Resolution
Appeals of Service Termination in Skilled Nursing Facilities, Home Health Agencies, Hospice and Comprehensive Outpatient Rehabilitation Facilities Review
Anti-dumping review (Emergency Medical Treatment & Active Labor Act - EMTALA)
Hospitals with emergency departments are prohibited from transferring patients to another facility without screening for emergency medical conditions, stabilizing those conditions and determining if the benefit of transfer outweighs the risk.
When Centers for Medicare & Medicaid Services (CMS) requests IFMC to review EMTALA cases, we assess whether any of those requirements were ignored. Review is conducted on all payor sources.
Higher-weighted Diagnosis Related Group (DRG) adjustment review
Case review is required for all claim adjustments resulting in a higher payment.
In addition to validating coding accuracy, the review is aimed at ensuring the
diagnosis and procedures submitted in the claim are supported by the medical
record documentation.
Hospital-Issued Notices of Noncoverage (HINN) review
Hospital staffs issue HINNs when they determine the care a Medicare consumer is receiving or about to receive is not covered by Medicare because it is not medically necessary or could safely be provided in another setting. IFMC reviews HINNs when requested by Medicare consumers, their representatives or a hospital.
To view guidelines for issuing hospital issued notices of noncoverage and sample HINNs, see Pub 100-04 Medicare Claims Processing Manual, transmittal 1257, change request 5622, or visit www.cms.hhs.gov/BNI
Hospital Discharge Appeals
Hospitals must deliver a revised version of the Important Message from Medicare
to inform Medicare beneficiaries who are hospital inpatients about their
hospital discharge appeal rights. Notice is required both for Original Medicare beneficiaries and for those enrolled in Medicare health plans. Beneficiaries who choose to appeal a discharge decision will receive a more detailed notice.
Click here for more information on Hospital Discharge Appeals
Consumer complaint review/Alternative Dispute Resolution
CMS offers voluntary alternative dispute resolution via mediation as an option for resolving some Medicare beneficiary complaints. An impartial professional mediator facilitates these face-to-face meetings between a patient and a provider.
Click here for more information on Mediation
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Appeals of Service Termination in Skilled Nursing Facilities, Home Health
Agencies, Hospice and Comprehensive Outpatient Rehabilitation Facilities
Review
IFMC provides a process by which a beneficiary may obtain an expedited determination in response to the termination of provider services in a variety of provider settings including: Hospital, Skilled Nursing Facility (SNF), Home Health, Comprehensive Outpatient Rehabilitation Facility (CORF) and Hospice.
Click here for more information on
appeals of service termination in Skilled Nursing Facilities, Home Health
Agencies, Hospice and Comprehensive Outpatient Rehabilitation Facilities
Review
To view guidelines for issuing discharge appeals, visit www.cms.hhs.gov/BNI