As part of Quality Insights's contract with the Centers for Medicare & Medicaid Services (CMS), the review services department has the responsibility to ensure that Medicare beneficiaries receive services that meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our task involves reviewing medical records. Non-physician as well as physician reviewers perform these reviews. Quality Insights maintains a complete roster of board-certified physicians from various specialties who provide clinical input relating to the care a patient received.

In addition, since January 2004, we have been performing appeals when certain services are being discontinued for Medicare Advantage enrollees in the settings of skilled nursing, home health care, and comprehensive outpatient rehabilitation facilities. Beginning July 1, 2005, we began doing appeals (called BIPA) for traditional Medicare patients whose services are being discontinued in hospice facilities as well as in the settings mentioned previously.

The review services Web site offers information on beneficiary protection, the beneficiary complaint process, BIPA, and much more.