Overview
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, CFMC 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.
Quality Measures
- 90% of all cases reviewed by the QIO will meet timeliness of
review standards
- Beneficiary satisfaction with the complaint process: Percentage
of beneficiaries completing the satisfaction survey who are
satisfied or very satisfied with the complaint process
- Beneficiary satisfaction: Percentage of complainants agreeing to
complete satisfaction survey from completed complaint cases
- Quality Improvement Activities (QIAs): Percentage of QIAs among
cases with confirmed quality of care concerns
- Improvement Resulting from Quality Improvement Activity –
System-Wide Change
- Percentage of participating RHQDAPU PPS Hospitals who receive
the 2.0% Inpatient RHQDAPU Annual Payment Update
Contact Information
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