Medical Review

The New Mexico Medical Review Association (NMMRA) is the only federally-designated organization in New Mexico that performs peer review. Under CMS regulations and guidelines, medical cases come to NMMRA for review from three major sources:

• Beneficiary complaint concerning his/her care 
• Mandatory review requested by other agencies or hospitals

All medical review done by NMMRA requires evaluation of the medical record of the Medicare beneficiary. The goal of this review is to determine whether the health care provided:

• Was reasonable and necessary
• Was provided in the appropriate setting
• Met professional recognized standards

Reasonable and necessary care is defined by CMS as care that is needed to: diagnose and treat an illness or injury, improve functioning of a malformed body member, prevent illness, or palliate and manage a terminal illness. The appropriate setting is the one that requires the least resources to deliver the safety of care required by the beneficiary.

Beneficiary Complaint Review

CMS requires NMMRA to review all written and phoned-in complaints received from a Medicare beneficiary or his/her designated representative alleging that quality of service covered by Medicare does not or did not meet professional recognized standards. The complaint may also cover a utilization issue and be reviewed by NMMRA.

The services that NMMRA reviews must be covered benefits under the Medicare program whether the beneficiary was covered at the time of the service or not and the services must have been furnished by a provider or practitioner that is participating in the Medicare program. Regulations authorize NMMRA to access and review medical records pertinent to health care services furnished to the Medicare beneficiary in all settings in which Medicare is a payor within the State of New Mexico.

For complaints concerning payment issues or end stage renal disease (ESRD) services, NMMRA will refer the beneficiary's complaint to the appropriate agency or ESRD network organization.

Beneficiary Complaint Review Process

Once the beneficiary has notified NMMRA of a concern, records are requested and a peer review process is applied to resolve the complaint. The process to complete a review for a beneficiary complaint can take up to 165 days. A signed acknowledgement of receipt of the complaint is required from the beneficiary and medical records are requested from the provider or practitioner when the beneficiary makes his/her complaint. There are provisions made for complaints that are anonymous or made by a beneficiary advocate as well, but they follow the same process without the signed acknowledgement.

Once the records are received, a nurse reviewer screens them to choose the appropriate peer reviewer. If the peer reviewer has any concerns after completing the initial review, an opportunity is afforded the involved practitioners and/or providers to submit additional information for consideration. Often not everything known about the patient or the circumstances of the care being considered are documented in the record. Once the peer reviewer has the opportunity to re-evaluate the information provided by all of the parties involved, a final determination is rendered and notification is sent to both the care providers and the patient.

Recognizing that there are sometimes sensitive issues present in these determinations, a notice of disclosure is sent to the provider and/or involved practitioner to comment on the final response to the complainant. This notice, if it concerns the actions of a physician, allows the involved practitioner to consent to or prohibit the disclosure of the review findings to the complainant. In the event that the review involves only a provider (institution or hospital), the involved practitioner/attending physician is asked to render an opinion regarding whether releasing review findings directly to the beneficiary would be harmful to the beneficiary.

If a quality of care concern is substantiated during the review process, the concern is recorded in a database and monitored over time for trends. Depending on the seriousness of the concern and how it is rated, the physician and/or provider may be asked to submit an action plan to prevent similar issues from arising in the future.

Regardless of the outcome of the review and opinion of the physician on the benefit to the patient of receiving the results, a response must be sent to the patient. It will be a very general response if the review findings are not allowed to be released by the physician. Often this general response is not very satisfactory to the patient even though there may be significant work behind the scenes to correct any problems that were found.

After reviews are completed, satisfaction survey questions are asked of the beneficiary, the provider and the practitioner about the process to continue to improve the program.

Mandatory Review

Mandatory review cases come from multiple sources.

• The Fiscal Intermediary may request a review of certain Medicare excluded procedures and diagnoses for a medical necessity determination.
• A hospital may determine that the original DRG billed may not appropriately reflect the service provided and they may make a request for a higher-weighted DRG.
• CMS randomly selects medical charts from Long-term Acute Care Hospitals for review of medical necessity, accuracy of coding and appropriateness of care.
• CMS selects medical charts where a Hospital-Issued Notice of Noncoverage has been issued and there is beneficiary liability for payment for review of medical necessity, accuracy of coding and appropriateness of care.
• Other reviews as mandated by CMS.

All mandatory reviews are performed following designated CMS guidelines.

External Quality Review (EQR)

In addition, NMMRA performs external quality review for state contractors. These reviews include:

• Utilization managment denials
• Grievance and appeals
• Care coordination/case management
• Transition of care
• Individuals with Special Health Care Needs (ISHCN)
• Performance measures
• Performance improvement projects

 For additional information about EQR, please click here.