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Beneficiary Protection
Overview
As part of its Medicare contract, Qualidigm conducts beneficiary protection activities that focus on case review and quality improvement.
Case review:
The primary types of review that Qualidigm conducts include: utilization review, quality of care review including responding to beneficiary concerns and appeals, certain provider notices, and review of potential anti-dumping cases.
When reviewing a case, Qualidigm considers the medical necessity and the quality of the services provided, and whether they were provided in the appropriate setting (hospital, nursing home, home care or physician office). Besides conducting reviews in response to requests from beneficiaries or their representatives, Qualidigm also reviews cases based on requests from Medicare or other agencies, as well as health care providers.
Quality Improvement:
Qualidigm identifies opportunities for improvement in the review process through feedback provided by beneficiaries who are surveyed to determine their satisfaction with the complaint process. When concerns with the review process are identified that are within the purview of the QIO, Qualidigm initiates a plan to resolve them.
Qualidigm also identifies opportunities for improvement in the quality of provider services identified through the case review process and data analysis. When improvement opportunities are identified, quality improvement activities (QIAs) are initiated to resolve them so they do not recur.
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 their rights and protections under the Medicare program.
Overview | Qualidigm Activities | Links, Tools & Resources | Team Members
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Links, Tools & Resources
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.
Overview | Qualidigm Activities | Links, Tools & Resources | Team Members
