Louisiana Health Care Review
THE MEDICARE QUALITY IMPROVEMENT ORGANIZATION
Case Review

Louisiana Health Care Review (LHCR) responsibilities as a Quality Improvement Organization (QIO) are to protect Medicare beneficiaries' rights, improve quality of care, and protect the integrity of the Medicare Trust Fund. Each case reviewed by the QIO is for the purpose of one of these three objectives.

Each case is reviewed to determine if admission was appropriate, reasonable, and medically necessary, whether the services met professionally recognized standards of health care, and whether all diagnosis and procedures billed are reflected in the chart documentation. 

Currently, Interqual’s Severity of Illness and Intensity of Service (SI/IS) inpatient criteria and invasive procedure criteria are the screening tools utilized for utilization issues. CMS generic quality screens are used for quality screening.

Nurse working with paperwork at a desk in the hospital

Beneficiary Complaint Response Program
Louisiana Health Care Review (LHCR) 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.

Currently each beneficiary complaint goes through a medical record review process that can take from 85 to 165 days for completion.  LHCR’s physician reviewers (PR) review the medical record to determine in any quality of care concerns exist. No direct dialogue between the beneficiary and the physician or provider occurs.  The beneficiary may not know the result of the review if the physician or provider does not agree to release this information.

Beginning September 2003, LHCR will offer a new option for reviewing beneficiary complaints – Mediation.  All cases will go through a preliminary review by a physician reviewer before referral for possible mediation.

Helpful Information about Beneficiary Complaint Response Program and Mediation

Concerned about your healthcare treatment?
Let’s talk.

 This fact sheet is designed to answer basic questions about mediation. When you call Louisiana Health Care Review, Inc. to file a complaint, a review case manager will give you more details. If your complaint is suited for mediation, the process will be further explained to you.
Mediation in the Medicare Beneficiary Complaint Response Program The proven benefits of mediation will soon be applied to the nation’s Medicare program, the health insurer for 42 million beneficiaries across the country.
Mediation Mediation means Dialogue. All cases will go through a preliminary review by a physician reviewer before referral for possible mediation.

Hospital Issued Notices of Non-Coverage (HINN) &
Notice of Discharge and Medicare Appeal Rights (NODMAR)
Hospitals (including ones with swing beds) have the authority to issue notices of non-coverage to beneficiaries or their representatives if the hospital determines that the care the beneficiary is receiving, or is about to receive, is not covered because it is not medically necessary, is not delivered in the most appropriate setting, or is custodial in nature. A HINN may be given prior to admission, at admission, or at any point during the inpatient stay.

Read more about Hospital Issued Notice of Non-Coverage and
Notice of Discharge and Medicare Appeal Rights (NODMARs).
 
Hospital- Requested Higher-Weighted DRG Assignments
Hospitals submit requests for higher-weighted DRG assignment directly to the fiscal (Trispan or Mutual of Omaha) intermediary for processing and payment. All such requests granted by the intermediary are subsequently selected by Center for Medicare and Medicaid Services (CMS) for Louisiana Health Care Review (LHCR) review on a post-payment basis. When reviewing hospital-requested higher-weighted DRG assignments, LHCR performs a medical necessity review, a quality review, and DRG validation. The purpose of DRG validation is to ensure that diagnostic and procedural information and the discharge status of the patient, as coded and reported by the hospital on its claim, matches both the attending physician's description and the information contained in the patient's medical record. When DRG validation results in lower payment, the hospital, physician and intermediary are notified of the coding error that resulted in increased payment when the hospital-requested higher-weighted DRG assignments.

The hospital may request a re-review of LHCR’s decision to change a DRG assignment when the change results in a lower payment to the hospital.
Emergency Medical Treatment and Active Labor Act (EMTALA)

Congress enacted The Omnibus Budget Reconciliation Act of 1990 (OBRA 90), to prevent hospitals from refusing to treat individuals requiring emergency care or inappropriately transferring or discharging individuals with unstable emergency conditions. Hospitals with emergency departments are prohibited from transferring patients to another facility without screening for emergency medical conditions, stabilizing these conditions and determining if the benefit of transfer outweighs the risk.

 When the Centers for Medicare & Medicaid Services (CMS) requests Louisiana Health Care Review (LHCR) to review EMTALA cases (five-day or 60-day reviews), we assess the following:

  • whether the individual had an emergency condition;

  • whether the individual was transferred appropriately;

  • whether the individual’s emergency condition was stabilized;

  • whether the certification that the benefits of transfer outweighed the risks was correct; and

  • whether there were any medical utilization or quality of care issues involved in the case.

 LHCR’s review findings are forwarded to CMS for further investigations.
Medicare Coverage Review
Items/services that are experimental or are not efficacious are excluded from Medicare coverage in all cases, regardless of patient illness, treatment history, or setting. Certain other items/services are also excluded from coverage in all cases even though needed by the patient (e.g., routine physical checkups or hearing aids).

The intermediary/carrier, within the parameters of Medicare policy, has the authority to determine whether specific items/services are covered or excluded from coverage. The intermediary/carrier must follow existing national Medicare policy (e.g., criteria in the Coverage Issues Manual). When no national policy exists, intermediaries/carriers have the authority to establish local coverage policy. For some items/services (e.g., blepharoplasty or breast reconstruction following mastectomy), coverage depends upon meeting specific conditions of medical necessity and reasonableness, such as type and severity of illness. The intermediary refers inpatient claims to you involving items/services that require a medical necessity determination before the claims can be considered covered and payment can be made.

For those cases referred to Louisiana Health Care Review for coverage review, we determine if the admission is medically necessary, and if the services provided adhere to Medicare coverage guidelines.

Referrals from Other Agencies
Medical reviews may be requested from Congressional Offices, Fiscal Intermediary (Trispan or Mutual of Omaha) or Carrier (Medicare Part B Services), Center of Medicare and Medicaid Services (CMS) or the Office of the Inspector General (OIG).  Louisiana Health Care Review reviews all cases requiring a medical necessity or quality of care determination.

 


For more Quality Improvement
resources, visit www.medqic.org

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This Web site is produced by Louisiana Health Care Review, Inc., the Quality Improvement Organization (QIO) for Louisiana, under contract 500-99-LA02 with the Centers for Medicare & Medicaid Services (CMS). The contents presented do not necessarily reflect CMS policy.

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Louisiana Health Care Review, Inc. © 2002-2007
8591 United Plaza Boulevard, Suite 270
Baton Rouge, Louisiana 70809
Telephone: 225-926-6353 / Fax: 225-923-0957