Higher Weighted DRG Review
Quality Insights reviews cases from a variety of sources to determine the following:

  • Medical necessity
  • Quality of care
  • DRG validation determinations
Quality Insights reviews the following:

  • All hospital-requested higher weighted DRG assignment cases accepted by the Fiscal Intermediaries (FIs)/Medicare Administrative Contractors (MACs) 
  • Coverage decision referrals from FIs/MACs
  • Any other review required by the QIO manual, including
  • Reconsiderations for quality of care concerns,
  • DRG changes
  • Admission denials
  • Readmission reviews
  • Outliers
  • Prepare cases for administrative law judge (ALJ) hearings
Quality Insights also monitors hospital compliance in securing physician acknowledgment statements.