Purpose of PRO Review for the Individual Medicare Beneficiaries

60.1 - Purpose of PRO Review for the Individual Medicare Beneficiaries (Rev. 1, 09-11-02) The PROs review items or services provided to Medicare beneficiaries to determine: • Whether services provided or proposed to be provided are reasonable and medically necessary for the diagnosis and treatment of illness or injury, or to improve functioning of a malformed body member, or for prevention of an illness, or for the palliation and management of terminal illness; • Whether those services furnished or proposed to be furnished on an inpatient basis could be effectively furnished on an outpatient basis, or in an inpatient health care facility of a different type; • Medical necessity, reasonableness, and appropriateness of inpatient hospital care for which additional payment is sought under the outlier provisions of PPS; • Whether a hospital has misrepresented admission or discharge information, or has taken an action that results in the unnecessary admission of an individual entitled to benefits under Part A, unnecessary multiple admissions of an individual, or other inappropriate medical or other practices with respect to beneficiaries, or billing for services furnished to beneficiaries; • The validity of diagnostic and procedural information supplied by the provider to the A/B MAC (A) for payment purposes; • The completeness and adequacy of hospital care provided; and • Whether the quality of services meets professionally recognized standards of health care. These activities enable PROs to determine whether Medicare payment may be made for the services claimed and to identify and initiate corrective action where appropriate. PROs have the authority to deny Medicare payment for medically inappropriate and unnecessary admissions. They also investigate individual beneficiary complaints about the quality of care received.