Quality of Care Concerns

NMMRA is federally designated by Medicare to conduct medical case reviews in New Mexico. Requests for review can be made if a Medicare beneficiary or his/her representative has a concern about the quality of health care provided or the appropriateness of the medical treatment received for a specific health condition.

Quality of care reviews do not involve billing concerns, administrative problems, denial of services, or any other non-medical complaint that cannot be found in the medical records. Even if a concern does not meet the criteria for a quality of care review, we can still refer it to the appropriate organization.

How to Request a Quality of Care Review

A beneficiary or his/her representative can either call the NMMRA Helpline at 1-800-663-6351 or write to NMMRA to request a quality of care review. A nurse or case review manager answers the Helpline and asks for the following information:

• Beneficiary's name
• Dates on which the medical care was provided
• Name of the physician that provided the care
• Beneficiary's Medicare number
• Medical facility where the care was provided
• Description of the specific concerns

What to Expect When Requesting a Quality of Care Review

After this information has been collected, the nurse or case review manager will send a packet of information to the beneficiary or his/her representative including:

• A complaint form, summarizing the complaint, for signature
• A consent form to reveal the beneficiary's identity
• A consent form to refer concerns to any additional agencies if that is necessary after completing medical case review

Requests for additional information or designation of a representative may also be necessary depending on the concerns in the case, but the nurse or case review manager will discuss that on the call.

NMMRA will then request the medical records and examine them.

The review process can take up to 165 days because every effort is made for all parties to discuss the care that was given. The nurse or case review manager will make follow-up calls to the beneficiary or his/her representative to keep them informed of the progress of the review.

The skills of an independent physician with training and specialization appropriate to the case being examined are used to make the most fair decision possible on whether the care provided to the beneficiary met recognized standards of care.

Outcomes of a Quality of Care Review

After all discussion is collected and the physician reviewer has completed the review, re-evaluation and determination of the case, a letter is sent to all involved parties.

Federal regulations require that permission be obtained from a physician to release in-depth review findings. NMMRA is committed to providing the beneficiary and/or his/her representative with as much information as possible.

For more information about Quality of Care Concerns and Reviews, please call the NMMRA Helpline at 1-800-663-6351.