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Beneficiary Protection
Overview
As part of the Medicare 9th SOW contract, Qualidigm will continue to work on beneficiary protection activities with two areas of focus statutory and regulatory mandated review, and quality improvement.
Focus on case review:
The primary categories of review include: utilization review, quality of care review including review of beneficiary complaints, review of beneficiary appeals, certain provider notices, and review of potential anti-dumping cases. The review process itself remains essentially the same as in the previous contract.
Qualidigm Activities
Qualidigm will be identifying opportunities for improvement in its internal review process through feedback provided by beneficiaries who will be surveyed to determine their satisfaction with the complaint process and outcomes. When concerns are identified that are with the purview of the QIO, Qualidigm will initiate a plan to resolve them.
Qualidigm will also be identifying opportunities for improvement in the quality of provider services. As in prior years, the opportunities will be identified through the case review process. During this contract period, the QIOs are expected to utilize data analysis as an activity to identify opportunities. When improvement opportunities arise, the action to resolve is so that it does not occur in the future provision of services. This provided effort is referred to with the Medicare program as a QIA (quality improvement activity).
The review process applied to each case includes consideration of medical necessity and quality of the care, and whether they were provided in the appropriate setting (hospital, skilled nursing facility, home care agency or physician office). The review of a case can be triggered for a variety of reasons as described above. Some of the cases are identified by Medicare beneficiaries or by their family/representatives.
Qualidigm provides resources - free of charge - to help Medicare beneficiaries and their families (or caregivers) with important questions or concerns about:
- Reviewing a quality of care concern
- Appealing a provider’s decision to discontinue Medicare coverage of services
- Understanding theirs rights and protections under the Medicare program.
Overview | Qualidigm Activities | Tools & Resources | Links | Team Members
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Tools & Resources
Coming soon.
Links
Coming soon.
Team Members
Contact Us:
To speak with a member of our staff, call Qualidigm toll-free at 1.800.553.7590. Our hours are Monday through Friday, 8:00 am to 4:30 pm. However, you can leave a message at any time (even outside of our business hours), and your call will be returned.