Saturday, July 23, 2016

What is Livanta and QIO


Quality Improvement Organization Complaint Process

For Tufts Medicare Preferred HMO members concerned about the quality of the care received can also file a complaint with Livanta at 866.815.5440. Quality Improvement Organizations (QIO), such as Livanta, are groups of doctors and health professionals that monitor the quality of care provided to Medicare beneficiaries. Livanta Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for Massachusetts. The Livanta review process is designed to help prevent any improper practices. This process is separate and distinct from the Tufts Medicare Preferred HMO grievance (complaint) process.  

The QIO is under contract to the CMS to conduct medical reviews and other functions with respect to Medicare beneficiaries.


Livanta

Livanta is responsible for the quality of care review of services provided to Massachusetts Medicare patients enrolled in Medicare Advantage products with CMS. This includes Tufts Medicare Preferred HMO members.

The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended by the Omnibus Budget Reconciliation Act (OBRA) of 1986, requires Tufts Health Plan to participate in an external review of its QI program for members enrolled in Tufts Medicare Preferred HMO. The responsibilities of each organization that conducts the external review of the Tufts Medicare Preferred HMO plan are delineated in the Tufts Health Plan/Livanta agreement.




Livanta Reviews

Livanta maintains a review system to ensure that services provided to Medicare beneficiaries enrolled in Medicare health plans are of adequate quality across all settings. This review system addresses the following issues:

** Appropriateness of treatment

** Potential for under-utilization of services

** Accessibility to services

** Potential for premature discharge of patients

** Timeliness of services provided

** Appropriateness of the setting for the provision of services

** Appropriateness of the Medicare health plan’s activities to coordinate care, such as the adequacy of discharge planning and follow-up of abnormal diagnostic studies
Livanta will notify Tufts Health Plan Medicare Preferred regarding issues that include results of Livanta’s review activities, unless otherwise specified in the Livanta/CMS contract. These issues will be identified as Quality of Care concerns or documentation concerns.

Tufts Health Plan Medicare Preferred will be notified when a Livanta review indicates a quality problem regarding an out-of-plan emergency or urgently needed care that an out-of-plan hospital, skilled nursing facility (SNF), or other health care facility provided to a Tufts Medicare Preferred HMO member, and the problem is attributable to the institution. However, the quality problem identified with respect to these services will be attributed to the out-of-plan provider/practitioner, rather than to Tufts Health Plan Medicare Preferred.

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