| Medicare Quality Improvement | |
| Beneficiary Discharge Appeals | |
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Medical Review Services
Utilization Review/Management
For more than 30 years, HSAG has been performing utilization review of health services to ensure that patients receive optimal medical care that is medically necessary and delivered in the appropriate setting. Utilization review may be performed before, during, or after the provision of health care services, and includes precertification as well as concurrent and retrospective case review. HSAG has extensive utilization management experience, having reviewed more than 300,000 medical and surgical cases for medical necessity, appropriate level of care, and coding accuracy.
Case Management
HSAG provides case management/disease management services for individuals with complex medical needs. Our staff includes board-certified physicians, registered nurses, certified case managers, and nationally recognized experts in health care management. HSAG also contracts with more than 150 multi-specialty, board-certified physician advisors who assess patients’ medical conditions to determine medical necessity, appropriateness of treatment plans, and whether the quality of delivered care meets evidence-based community standards.
TRICARE
TRICARE is a component of the Military Health System that was created in the early 1990s as a managed care program to better provide health care services for active duty service members, military retirees, and their families. TRICARE Management Activity (TMA) is the government entity under the Department of Defense (DoD) responsible for the management of TRICARE. TMA contracts with three managed care support contractors, one TRICARE dual-eligible fiscal intermediary contractor, and six designated providers who are enrolled in the US Family Health Plan. These contractors develop networks of health care providers to perform services outside of the military treatment facilities.
Beneficiary Discharge Appeals
When Medicare beneficiaries are discharged from hospitals, skilled nursing facilities, home health agencies, hospice, or comprehensive outpatient rehabilitation facilities they are entitled by Federal Statute to appeal their discharge. As the Medicare quality improvement organization (QIO) for Arizona and California, HSAG is the designated agent to review all beneficiary discharge appeals—also known as expedited reviews or fast track appeals—to determine if covered services should be continued and if the patient should be allowed to stay in his or her health care setting.
Beneficiary Complaints
As the Arizona and California Medicare quality improvement organization (QIO), HSAG administers the Medicare Beneficiary Protection Program in these states. This program is a core function of QIOs and is intended to ensure that the quality of services received by Medicare beneficiaries meets professionally recognized standards of care, are medically necessary and are delivered in the most appropriate setting. HSAG physicians and nurses, licensed in the state where the patient’s health care is provided, examine all written quality-of-care complaints from Arizona and California Medicare beneficiaries or their designated representatives by evaluating the medical records pertaining to the complaint.
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