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Important NMMRA Medical Review Process Changes

For the past seven years, under the federal contract NMMRA has held and currently holds with the Centers for Medicare & Medicaid Services (CMS) as the Medicare QIO for New Mexico, NMMRA has provided seven-days-a-week staffing for termination of services and discharge appeals cases. These entail review of cases where Medicare beneficiaries receiving care from hospitals, nursing homes, home health agencies and hospices are having that care terminated by a provider on the basis that it is no longer covered by Medicare but that the beneficiary believes is still medically necessary under the federal guidelines. When NMMRA receives an appeal request, the review performed is conducted on an expedited basis.

The nature of these appeals is that they are unpredictable in terms of work flow yet have to be staffed to be able to respond under very short timeframes. With a low volume of such cases, the cost to an individual organization like NMMRA, particularly under the tight budget for this aspect of the current CMS contract, is extremely problematic. While we endeavored in August and September to maintain the previous handling directly through NMMRA staff, it was quickly evident that we could not sustain the process that has been in place in the past and have had to implement efficiencies to the current process that will affect providers in New Mexico.

By virtue of the formal affiliation NMMRA has with HealthInsight, headquartered in Salt Lake City, Utah, and with large-scale review operations in Las Vegas, Nev., NMMRA has begun having appeals intake processed through the Las Vegas office where the Nevada QIO contract is also administered. As a federally qualified QIO, HealthInsight Nevada is governed by the same confidentiality requirements as NMMRA. Providers receiving requests for Medicare records from HealthInsight Nevada should feel comfortable sending those records directly to the Las Vegas office. It is critically important for our providers to understand that they can always call us for information and assistance in reaching Nevada staff but also that all physician review of such cases will be performed by New Mexico-based physicians, licensed to practice in the state.

In a similar vein, quality-of-care intake is being performed by the CMS-designated Beneficiary and Family Centered Care National Coordinating Center, located with the Florida QIO contractor, Florida Medical Quality Institute. CMS initiated this process to provide a central location to initiate all quality-of-care reviews and allow Medicare beneficiaries, families or representatives to voice their concerns regarding the quality of care received. “That process has been in place since August 8 but is understandably still the source of some confusion among providers," said John Seibel, MD, NMMRA medical director. "As with appeals cases, it is important to understand that the physician review of these cases is performed by New Mexico physicians."

For all other kinds of review required under the NMMRA contract with CMS, the process remains exactly as it is now.

For any questions, please contact Andy Romero at (505) 314-9009 or aromero@nmqio.sdps.org.