One of Qualis Health's functions as the Medicare Quality Improvement Organization (QIO) for Idaho and Washington is to make sure people on Medicare receive the healthcare they are entitled to, and that the care they receive meets nationally recognized quality standards by performing certain types of mandatory case review.

Our goals in Mandatory review include:

• Improving quality of care for beneficiaries by ensuring that beneficiary care meets recognized standards of healthcare.
• Protecting the integrity of the Medicare trust fund by ensuring that Medicare only pays for services and items that are reasonable and medically necessary and are provided in the most economical setting.
• Protecting beneficiaries by expeditiously addressing individual cases

Types of Mandatory Review conducted by Qualis Health include:

• Beneficiary Improvement and Protection Act (BIPA) Appeals
• Medicare Advantage Expedited Appeals (aka "Grijalva Appeals")
• Alleged anti-dumping violations (EMTALA)
• Beneficiary complaints
• Hospital notices of noncoverage (HINNs)
• Notices of Discharge and Medicare Appeal Rights (NODMAR)
• Beneficiary requests for immediate review of Medicare Advantage organization-issued notices of noncoverage
• Hospital-requested higher-weighted DRG adjustments
• Assistant surgeons during cataract surgery
• Potential gross and flagrant violations
• Referrals