Who currently performs utilization and quality control review of health care furnished or to be Medicare beneficiaries?
Currently, utilization and quality control review of health care furnished or to be furnished Medicare beneficiaries is primarily performed by several entities. These include:
Medicare Administrative Contractors (MACs): MACs are private insurance companies that contract with the Centers for Medicare and Medicaid Services (CMS) to administer Medicare Part A and Part B claims. They are responsible for reviewing claims for medical necessity, accuracy, and compliance with Medicare regulations.
Quality Improvement Organizations (QIOs): QIOs are private, non-profit organizations that are designated by CMS to perform quality reviews of health care services provided to Medicare beneficiaries. They monitor and evaluate the quality and appropriateness of care, identify areas for improvement, and work with providers to implement quality improvement initiatives.
The Centers for Medicare and Medicaid Services (CMS): CMS conducts its own quality control and utilization reviews through its regional offices and contractors. They investigate complaints, review medical records, and conduct onsite visits to ensure compliance with Medicare regulations and standards.
Hospitals and Other Providers: Hospitals and other health care providers are also responsible for performing their own internal utilization and quality control reviews to ensure that the care they provide meets Medicare standards. They have quality assurance programs in place to identify and address any issues or deficiencies in care.
Beneficiaries: Medicare beneficiaries can also play a role in utilization and quality control review. They can report any concerns or complaints about their care to their providers, MACs, QIOs, or CMS. Their feedback helps identify problems and ensures that beneficiaries receive high-quality care.
These various entities work together to ensure that Medicare beneficiaries receive necessary, appropriate, and high-quality health care services.