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 COBRA/EMTALA reviews. Additionally, all cases in which a hospital requests reassignment of a claim to a higher-weighted 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.