Quality Screens

As the Medicare Quality Improvement Organization (QIO) for California, HSAG conducts case review activities as well as population-based quality improvement projects. Within its case review work, HSAG is contracted to meet three major goals:

• Protect the beneficiary's right to an expedited appeal regarding a hospital discharge or the discontinuation of skilled services, as well as answering questions related to the quality of care provided to the Medicare population.
• Protect the Medicare Trust Fund by ensuring that Medicare only pays for those services that are medically necessary and provided in the most appropriate setting.
• Improve patient care through quality improvement activities and/or projects.

HSAG uses tools to assist non-physician reviewers in screening medical records for both utilization and quality review. HSAG utilizes a nationally recognized screening tool (InterQual) for medical necessity reviews. It has also worked with its internal hospital team to reformat the quality review tools, which will be used during the review process not only to verify any beneficiary complaint but also to identify opportunities to improve care overall.

These quality review tools now include national clinical indicators for:

• Heart failure.
• Pneumonia.
• Acute myocardial infarction.
• The Surgical Care Improvement Project (SCIP) Strata 3
  (total hip replacement).
• The SCIP Strata 4 (total knee replacement).
• The SCIP Strata 5 (colon surgery).

For more information about these indicators, contact ccook@fmqai.com