Annual Medical Services Review Report
United States Virgin Islands
Virgin Islands Medical Institute, Inc. |
Time Frame: February 1, 2004 through January 31, 2005
A. Beneficiary Complaints
Under Medicare law, Quality Improvement Organizations (QIOs) review complaints about the quality
of care that Medicare patients receive. The complaints come from Medicare patients and/or their
representatives. In reviewing a complaint, the QIO looks at the services a patient received
and decides whether those services met standards of health care that are commonly accepted by
physicians and others in the medical community.
Quality of care complaints may involve more than one concern, due to the following: (1) more than
one quality of care concern in a single setting; (2) the same quality of care complaint for a
single patient episode of illness involving multiple settings and/or providers; or (3) more than
one quality of care concern involving more than one setting and/or provider. For example, a
Medicare beneficiary complaint related to a hospital stay might include several different quality
of care concerns or a beneficiary who was hospitalized and then moved into a skilled nursing
facility or other outpatient hospital setting might have the same quality of care concern occur
in each type of setting. Consequently, for a specific Setting or Provider type, the number of
quality of care concerns confirmed by the QIO may exceed the number of beneficiary cases reviewed.
Beneficiary Complaint Cases: Number and Review Results
| Number and Rate |
Review Results |
| Total cases reviewed by the QIO |
1 |
Cases with confirmed quality concern |
0 |
| Cases per 10,000 Part A Medicare beneficiaries |
|
Cases without confirmed quality concern |
1 |
| |
|
Cases in process (without completion date) |
1 |
Note: Individual cases may involve more than one setting and/or provider.
Complaint Cases by Setting or Provider
| Care Setting or Care Provider |
Total Number of Concerns |
Number and Percent of
Confirmed Concerns for the State |
| Number |
Percent (%) |
| Hospital |
1 |
0 |
0% |
Skilled Nursing Facility (SNF)
(includes SNF, swing and swing critical access) |
0 |
0 |
0% |
| Home Health Agency |
0 |
0 |
0% |
| Medicare Advantage |
0 |
0 |
0% |
| Physician |
0 |
0 |
0% |
| Other Provider |
0 |
0 |
0% |
Note: Individual cases may involve more than one setting and/or provider.
Complaint Cases with Confirmed Concerns: Type of Problem
The numbers below represent only complaints by beneficiaries or their representatives. They do not include
any other QIO reviews of medical services.
| Type of Concern Confirmed |
Total Number of Concerns |
Number and Percent of
Confirmed Concerns |
| Number of Confirmed Concerns |
Percent (%) of Total Confirmed Concerns |
| Inappropriate or unneccessary services |
0 |
0 |
0% |
| Inappropriate setting |
0 |
0 |
0% |
| Services with a confirmed quality concern |
0 |
0 |
0% |
B. Hospital Admission and Continued Stay Concerns
Under Medicare law, QIOs review the need for inpatient hospital care. They help determine whether
a patient received care in the proper place or “care setting.” This review may take place at two
different times, either during or after a hospitalization. In the first instance, patients or their
representatives ask the QIO to review a “Hospital Issued Notice of Non-Coverage,” or HINN, in which
the hospital informs a patient that either an admission or a continued stay in a hospital is not
needed. In such cases, the QIO conducts an “immediate review,” whereby the QIO reviews the case
(within 2 working days following the beneficiary’s request for a pre-admission or admission HINN
and within 30 days after discharge or when the beneficiary was not admitted to the hospital) and
issues either a denial notice or a notice explaining that the care would be, or is, covered.
In other cases where a hospital issues a HINN, but the patient does not immediately ask for a review,
the QIO reviews selected cases after the fact in what is called “retrospective review.” In all reviews,
the QIO staff looks carefully at the patient’s medical record to decide if an admission or continued
stay is/was needed.
Beneficiary Notice Reviews
| Type/Timing of Review |
Number of Cases |
Review Results |
| Appropriate Cases (Agree with Notice) |
Inappropriate Cases (Disagree with Notice) |
HINN FSS Preadmission Notice
Concurrent Immediate Review |
0 |
0 |
0 |
HINN FSS Preadmission Notice
Non-Immediate Review |
0 |
0 |
0 |
HINN FSS Admission Notice
Concurrent Immediate Review |
0 |
0 |
0 |
HINN FSS Admission Notice
Non-Immediate Review |
2 |
1 |
1 |
HINN Continued Stay Notice
Immediate Review
Attending Physician Concurs |
0 |
0 |
0 |
HINN Continued Stay Notice
Concurrent Non-Immediate Review |
0 |
0 |
0 |
HINN Continued Stay Notice
Attending Physician Does Not Concur |
0 |
0 |
0 |
| HINN Continued Stay Retrospective |
0 |
0 |
0 |
| HINN Retrospective Monitoring Review |
0 |
0 |
0 |
| NODMAR Immediate Review (MA) |
0 |
0 |
0 |
| MA Appeal Review (CORF, HHA, SNF) |
0 |
0 |
0 |
|
|
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