Medicare Peer Review Letter

Answer 1

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Peer Review Organizations (PRO's) are groups of practicing doctors and other health-care professionals who review the reasonableness, medical necessity, appropriateness, and quality of hospital care given to Medicare patients. PRO's primarily review complaints from beneficiaries and their representatives regarding Medicare Part A benefits. PRO's have the authority to deny payments if care is not medically necessary or not delivered in an appropriate setting.

PRO's process complaints in one of two ways: (1) concurrently -- while the patient is still in the medical facility receiving services; or (2) retrospectively -- after the patient has been discharged from the facility and is no longer receiving services. Whether the review is concurrent or retrospective, the timing of a PRO's review begins when a complaint is received in writing from a beneficiary or their representative and when the PRO has adequate information to begin the review (e.g. received medical records).

The PRO's must then acknowledge receipt of the complaint. This can be done either in writing or orally. For concurrent review, the PRO's must acknowledge receipt of the complaint within one full working day from receipt. The PRO's have five calendar days to acknowledge receipt for retrospective review.

Whether or not the reviewing PRO identifies any quality concerns during retrospective review, the PRO's completed review or notice must be sent to the medical provider within 15 calendar days after receipt of the medical records. Whether or not the reviewing PRO identifies any quality concerns during concurrent review, the PRO's completed review or notice must be completed and sent to the medical provider within one full working day after receipt of the medical records.

When a patient is admitted to a Medicare participating hospital, the patient receives a publication entitled "AN IMPORTANT MESSAGE FROM MEDICARE." It explains the patient's rights as a hospital patient and provides the name, address, and phone number of the PRO for that patient's state. Carefully read the description of the time frames in which you must take action depending upon various circumstances. Failure to make your appeal within the specified time frames may impact the portion of your hospital stay for which you will be responsible for paying.