Professionals

Medicare Case Review

Under contract with the Centers for Medicare & Medicaid Services (CMS), Qualidigm is responsible for case reviews related to both beneficiaries and providers. Case reviews associated with beneficiary protection typically result from appeals and quality of care complaints. Qualidigm is certified to conduct utilization review in Connecticut and Rhode Island.

Medicare 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 case review include: hospital issued notices to patients of non-coverage; managed care issued notices of non-coverage; and fiscal intermediary or carrier referrals. Current federal regulations continue to mandate COBRA/EMTALA review. Additionally, all cases in which a hospital requests reassignment of a claim to a higher-weighted DRG are examined. The 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.

• Medicare Appeals
• Quality Concerns