Beneficiary Protection

The beneficiary protection program is designed to monitor and improve the quality of care for people with Medicare. Under a new three-year contract with the Centers for Medicare & Medicaid Services (CMS), known as the 9th Statement of Work (SOW), quality improvement organizations (QIO) such as CCME will continue to complete mandated review activities that include:

• Reviewing the quality of care provided to beneficiaries.
• Reviewing beneficiary appeals of certain provider notices.
• Reviewing potential Emergency Medical Treatment and Women in Labor Act (EMTALA) cases.
• Implementing quality improvement activities as a result of case review activities.

Activities
For this contract, the nine tasks that CCME will focus on are:

• Case reviews
• Quality improvement activities (QIAs)
• Alternative dispute resolution (ADR)
• Sanction activities
• Physician acknowledgement monitoring
• Collaboration with other CMS contractors
• Promoting transparency through reporting
• Quality data reporting
• Communication (education and information)

Approach
For the 9th SOW, CCME will be increasing their efforts to link case review activities to improvements in the quality of care, specifically by developing quality improvement activities focused on system-wide changes. CCME will also be identifying opportunities, as in prior SOWs, through the case review process. When improvement opportunities arise, CCME will help providers design quality improvement activities (QIA) aimed at correcting these problems.

CCME is also focused on protecting the rights of people with Medicare by investigating complaints about quality of care. CCME provides free resources to help Medicare patients and their families (or caregivers) with important questions or concerns about:

• Reviewing a quality of care concern. 
• Appealing a provider’s decision to discontinue Medicare coverage of services. 
• Understanding their rights and protections under the Medicare program.