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Beneficiary Protection
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Beneficiary Protection activities will emphasize statutory and regulatory mandated review activity and quality improvement. Primary case review categories include utilization review, quality of care review, review of beneficiary appeals of certain provider notices and reviews of potential anti-dumping cases. Quality of care review includes the review of beneficiary complaints. In conducting reviews of beneficiary complaints, the QIO shall utilize a number of tools intended to address the beneficiary’s concerns, including implementation of quality improvement activities (QIAs), surveying of beneficiary satisfaction with the complaint process and outcome, and, if appropriate, alternative dispute resolution (ADR) mechanisms. The Tasks under this Theme will focus on conducting activities to meet, in an efficient and effective manner, regulatory and statutory requirements, to enhance QIO collaboration with the Beneficiary Complaint Survey Contractor, Fiscal Intermediaries (FIs), Carriers, Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), State Survey Agencies (SSAs), and the Office of Inspector General (OIG), and to clearly establish the link between case review and quality improvement through data analysis and improvement assistance.
Are You a Hospital Inpatient or Outpatient? If You Have Medicare - Ask!
This new publication from CMS is directed towards educating patients on the difference between inpatient stays, outpatient stays and what observation status is. This was created after several complaints came into CMS from trade associations, nursing home providers, and others that observation status affected the ability of some patients to appropriately qualify for skilled nursing services in the SNF, and may also affect them financially, if they did not realize they were actually not formally admitted to the hospital. Click here to get a copy of "Are You a Hospital Inpatient or Outpatient?"
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