Other Review Types

VHQC also reviews the following types of cases for Medicare:

Higher-Weighted Diagnosis-Related Groups: When a hospital wants to request that Medicare reimburse a case on the basis of a more highly weighted DRG, VHQC review coordinators examine the medical record for compliant coding, appropriate diagnostic grouping, utilization/medical necessity, and any other potential issues.

Emergency Medical Treatment and Active Labor Act, EMTALA: The Centers for Medicare & Medicaid Services refers cases of suspected "patient dumping" to VHQC for review. The patient does not have to be covered by Medicare. VHQC assesses whether the individual had an emergency medical condition that had not been treated or had not been stabilized before transfer.

VHQC no longer conducts reviews for the Hospital Payment Monitoring Program. This responsibility has been moved from QIOs to Fiscal Intermediaries, Medicare Administrative Contractors and the Comprehensive Error Rate Testing contractor. Read the HPMP update from CMS for more information.

Questions about Medicare case review? Call the toll-free VHQC provider hotline at 1-800-854-5244.