Quality of care concerns may be identified through the case review process when a reviewer recognizes that care failed to follow generally accepted guidelines or usual practice or care that may not have met professionally recognized standards of care.  Care concerns may also be brought to the attention of the review staff through a beneficiary complaint.

The goal of the quality review program is to identify opportunities for improvement.  CIMRO of Nebraska will be increasing its efforts to link case review activities to improvements in quality of care, specifically by developing quality improvement efforts focused on system-wide changes.  We will utilize all case review data to identify quality of care problems and design activities aimed at helping providers correct these issues.

The following briefly outlines the steps taken when there is a potential quality of care concern.

• Quality of care concern is noted through review or through a beneficiary complaint
• The medical record along with the concern is sent to a physician reviewer of the same/similar specialty for consideration.
• The physician reviewer identifies a potential quality concern.
• The provider is given an opportunity to send additional information or a more detailed explanation regarding the care delivered. 
• The additional information is sent back to the same physician reviewer.
• If the reviewer still determines that the concern is a valid issue, the healthcare provider is given another opportunity to provide additional information.
• Any additional information submitted for reconsideration is then sent to a different physician reviewer of the same/similar specialty to review the case.
• The final determination is made following this third level review.  In the event that the care issue was reviewed due to a beneficiary complaint, a final letter is sent to the person who initiated the complaint.
• A final letter is sent to the healthcare provider with the results of the review process.  Any opportunities for improvement are communicated to the involved provider.
• Recommendations for improvement may be provided by:
• Offering advice/education
• Recommend consideration of an alternative approach to future care
• Request the development/implementation of a Quality Improvement Plan (QIP)

For additional resources, please visit the Documents and Links section.