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Improving
Quality of Medical
Care
Handling Appeals
Investigating Complaints
Improving
Quality of Medical
Care
Quality
Improvement Organizations
(QIOs) have extended
their services from
hospitals and into
doctors offices into
additional health care
settings under a new
three-year contract
with the Centers for
Medicare and Medicaid
Services at the Department
of Health and Human
Services. The contract
calls for QIOs to improve
the quality of medical
care for Medicare beneficiaries
through 2005 in all
50 states, the District
of Columbia, Puerto
Rico, and the Virgin
Islands. QIOs focus
on:
QIOs
continue to implement
hospital projects to
improve clinical care
for heart attack, congestive
heart failure, and
pneumonia—all major
threats to the health
of the Medicare population.
These projects assist
hospitals in establishing
or refining clinical
systems to more consistently
provide the best care.
- Preventing
Surgical Infections
QIOs
are implementing projects
to reduce the incidence
of post-surgical infections.
These efforts will
improve timely and
appropriate use of
prophylactic antibiotics
before, during, and
after surgery.
- Improving
Care for Breast Cancer,
Diabetes, Flu
QIOs
continue outpatient
projects to help physicians
increase regular screening
for breast cancer and
improve care for diabetes
among Medicare beneficiaries.
QIOs are also continuing
to promote preventive
influenza and pneumococcal
(PPV) immunizations.
- Offering
Assistance to Nursing
Homes
QIOs
are providing technical
assistance to help
nursing homes implement
better systems of care
– with a focus on pain
management, avoidance
and treatment of pressure
ulcers, prevention
of infections, management
of delirium, and improvement
in walking. QIOs are
also helping the public
interpret data published
by CMS on the quality
of care in individual
nursing homes.
- Working
With Home Health
Agencies
QIOs
are offering home health
agencies education
and training to speed
their adoption of Outcomes
Based Quality Improvement
(OBQI) methodology
and techniques. QIOs
are also helping consumers
understand CMS-published
data on quality of
care offered by home
health agencies.
- Reducing
Racial, Ethnic, and
Rural Health Disparities
In
addition to implementing
projects that help
eliminate disparities
in care received by
ethnic and racial minorities,
QIOs are launching
new projects to improve
care in rural areas.
- Protecting
and Informing Patients
QIOs
are establishing Consumer
Advisory Councils to
increase communication
with Medicare beneficiaries
and consumer awareness
about quality of care.
In addition, QIOs continue
to review written complaints
alleging inadequate
quality of care. To
make the complaint
review process more
consumer-friendly,
case managers will
be assigned to assist
beneficiaries in using
the review process,
and QIOs will offer
mediation in some cases
to help resolve complaints.
QIOs are continuing
to respond to requests
for review of hospital
non-coverage notices
and review Emergency
Medical Treatment and
Active Labor Act (anti-patient
dumping law) cases.
- Supporting
Hospital Reporting
on Quality
QIOs
are helping hospitals
measure and report
data on the quality
of the care they provide,
laying the groundwork
for reporting to the
public. QIOs will assist
hospitals to comply
with new standards
set by the Joint Commission
on Accreditation of
Healthcare Organizations.
- Developing
New Methods to Advance
Quality of Care
QIOs
continue to conduct
special projects to
find new ways to speed
improvement in care
systems. For example,
a four-state special
QIO study in the mid-1990s
led to the successful
ongoing national QIO
effort to improve heart
attack care. One study
to be launched soon
will spur measurement
and improvement of
care provided in physicians
offices to patients
with chronic diseases.
QIOs will also begin
helping Medicare study
the incidence of adverse
events through the
Medicare Patient Safety
Monitoring System.
QIOs
continue to monitor
payment errors for
hospital services,
as well as to ensure
Medicare inpatient
hospital admissions
are medically necessary.
Overseeing
Appeals
Under contract
to the Centers for Medicare and Medicaid Services (CMS) QIOs in every state help
Medicare beneficiaries by handling appeals for continued and emergency coverage
and care. These efforts include:
Violations of
the Emergency Medical Treatment and Active Labor Act (EMTALA)
CMS refers potential
"anti-dumping" cases to QIOs for review. According to CMS, dumping occurs
when "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." If a case is a
potential dumping violation, a QIO conducts an expert medical review.
Hospital and
managed care plan issued notices of noncoverage (HINNs)
A Hospital Issued
Notice of Noncoverage (HINN) is created when a hospital determines that the care
a beneficiary is receiving, or is about to receive, is not covered because it
is not medically necessary, is not delivered in the most appropriate setting or
is custodial in nature.
Beneficiaries (or their representatives) who do not agree with the hospital's
determination can contact their state QIO for an expedited review. Once beneficiaries
or their representatives have requested a review, a physician reviewer examines
the medical record to determine if the HINN was appropriate.
Notice of Discharge
and Medicare Appeal Rights (NODMAR)
Each Medicare Plus
Choice (M+C) enrollee must receive a Notice of Discharge and Medicare Appeal Rights
(NODMAR) before being released from a hospital, once it is determined that inpatient
hospital care is no longer necessary. If beneficiaries disagree with the hospital
or M+C determination and remain in the hospital, they may immediately request
that a QIO perform a review to determine if the issuance of the NODMAR was appropriate.
Investigating
Quality of Care Complaints
QIOs investigate
written complaints received from Medicare beneficiaries or their designated representatives.
The complaints generally allege that the quality of services supplied by a health
care provider did not meet professionally recognized standards. QIOs review the
complaints and medical records to determine if this is true. Once the review is
completed, the QIO sends the beneficiary a letter summarizing the investigation's
findings. The QIO also checks for a pattern of poor care in a facility and works
with facilities and providers to improve care.
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