Overview/Objectives:

AQAF is responsible for protecting the rights of Alabama Medicare beneficiaries, improving the quality of care they recieve, and protecting the integrity of the Medicare Trust Fund. Each case reviewed by AQAF focuses on one of these three objectives. Current types of case review include beneficiary complaints, Hospital-Issued Notices of Non-coverage (HINNs), Notices Of Discharge and Medicare Appeals Rights (NODMARs), higher weighted DRGs, Emergency Medical Treatment and Active Labor Act (EMTALA), Medicare coverage review, and other referrals from the Fiscal Intermediary (FI)/Carrier, Office of Inspector General (OIG), and CMS.  Severity of Illness and Intensity of Service (SI/IS) inpatient criteria and invasive procedure criteria are used for screening cases for utilization issues. CMS generic quality screens are used for quality screening.

Beneficiary Complaints: AQAF is authorized to review all written complaints received from Medicare beneficiaries or their designated representatives. Reviews are performed when there are concerns about utilization issues, i.e. medical necessity/appropriateness of setting, or the quality of care they received from any health care provider regardless of setting. These cases are thoroughly reviewed to determine whether the services met professionally recognized standards of health care.

HINNs: A hospital, including one with swing beds, has the authority to issue notices of non-coverage (HINNs) to beneficiaries or their representatives. HINNs are given when the hospital determines that the care the beneficiary is receiving, or is about to receive, is not covered. Reasons for non-coverage include care that is not medically necessary, not delivered in the most appropriate setting, or is custodial in nature. AQAF is required to review HINNs when requested to do so by hospitals or by beneficiaries or their representatives. AQAF is also required to review HINNs in all cases where the beneficiary has incurred liability. The AQAF review process consists of screening by a nurse reviewer with referral to a physician who reviews the medical record and determines if the hospital appropriately issued the HINN. This is based on the condition of the patient and the services the patient required and/or received.

NODMARs: Medicare Advantage payers work with providers in issuing these notices to managed care patients. Patients have the same review rights as with HINNs and both provider and payer are responsible for issuing correct notices. The review process follows the HINN model.

HADs: AQAF is also responsible for reviewing hospitals' requests for higher weighted DRGs. AQAF staff reviews cases to ensure that diagnostic and procedural information, and the discharge status of the patient, as coded and requested by the hospital, match both the attending physician's description and the information contained in the patient's medical record.

EMTALA: Cases referred from CMS for potential anti-dumping violations are reviewed following a review protocol. 

Coverage: Referrals from the Medicare fiscal intermediary and carrier are screened by nurse reviewers for adherence to Medicare coverage guidelines. Questionable cases are physician reviewed.

Other Referrals from FI/Carrier/OIG/CMS: Cases are usually reviewed for quality of care using usual QIO review procedures.