Medicare Case Review

VHQC reviews healthcare services that are provided to Medicare patients in hospitals and a variety of outpatient settings.

The Centers for Medicare & Medicaid Services, patients and their representatives, managed care plans, and other Medicare contractors refer cases to VHQC when they have questions about quality, utilization or DRG assignment. Any case, regardless of its reason for referral, may be subject to quality review.

First-Level Review
An appropriately credentialed review coordinator conducts the initial review. If concerns or questions are identified, a physician reviewer in a like specialty also reviews the case. Every VHQC physician reviewer is certified by the American Board of Medical Specialties, actively practicing medicine in Virginia, and in good standing in his or her community.

If the physician reviewer identifies concerns, the provider is given an opportunity to respond. Determinations are made on the basis of medical record documentation and any additional information that the provider submits.

Appeals and Re-Reviews
Providers may request an appeal or a re-review, depending on the type of concern that was confirmed. If a second physician reviewer upholds the initial review decision, VHQC may require the provider to complete a quality improvement plan. Providers that demonstrate a pattern of concerns may be asked to participate in a Quality Improvement Activity designed to identify and address root causes.

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