VHQC  performs quality-of-care reviews in all settings paid by Medicare.

VHQC employs health professionals including physicians, nurses and health information administrators who serve as case reviewers.  Cases may be reviewed for utilization, quality and correct DRG assignment. Referrals for review come from a variety of settings including beneficiaries, Centers for Medicare and Medicaid Services (CMS), fiscal intermediaries (FI), managed care organizations and many other sources.

Overview Of QIO Case Review Process

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:

• Credentialed to practice medicine;
• Active license to practice and good standing in the community; and
• American Board Medical Specialties certified.

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 toll free provider hotline with questions about case review --
1-800-854-5244.