Case Review
VHQC performs quality-of-care reviews in all settings paid by Medicare.
Cases may be reviewed for utilization, quality and correct DRG assignment.
Referrals for review come from a variety of sources including beneficiaries,
Centers for Medicare and Medicaid Services, fiscal intermediaries, managed care
organizations and many others.
Medical professionals perform medical record reviews at VHQC. Initially, all
records are reviewed by either a nurse or a registered health information
administrator. If concerns or questions arise, the case is referred to a
physician reviewer in a like specialty. VHQC physician reviewers have the
following qualifications:
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to practice medicine;
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Active license to practice and good standing in the community; and
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Certified by the American Board of Medical Specialties.
When concerns are identified, the provider is given an opportunity to respond.
Determinations are made based on the response received and the documentation in
the medical record. Providers may request an appeal or a re-review of a
determination, as applicable, based on the type of concern confirmed.
Call VHQC's toll free provider hotline with questions about case
review --
1-800-854-5244.
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