Medical Case ReviewFMQAI’s role as a Quality Improvement Organization (QIO) is to protect the rights of Medicare beneficiaries, protect the Medicare Trust Fund, and improve quality of care. All of the cases that are reviewed by FMQAI must meet one of these objectives. Cases may be reviewed for utilization, quality, and correct DRG assignment. Referrals for the different types of reviews come from a variety of sources including Medicare beneficiaries and their families, the Centers for Medicare & Medicaid Services (CMS), and fiscal intermediaries (FI).
QIOs are also responsible for monitoring physician acknowledgement statements for hospitals. Because hospitals are paid under the prospective payment system based on the physician’s diagnoses, all newly credentialed physicians must sign a statement on file prior to his/her first admission to the hospital or first claim submission.