What is IPRO?
The federal government requires each state to have a Quality Improvement Organization (QIO) to evaluate and improve the quality of health care services and to protect the rights of medical beneficiaries. IPRO, an independent, not-for-profit organization based in Lake Success, New York, is the QIO for the State of New York. It also has the responsibility to protect and improve the quality of health care services to those in the Medicaid program.
Who we are
IPRO has a staff of more than 350 doctors, registered nurses, public health specialists, research scientists and other professionals and an additional 300 board-certified physician consultants available to perform medical review.
What we do
- Partner with doctors, hospitals, nursing homes, home health agencies and other health care providers to look for the best way to treat common diseases that affect Medicare beneficiaries.
- Review Medicare services provided for medical necessity, appropriate setting and the quality of care.
- Collaborate with providers on projects to improve the quality of health care services.
- Protect beneficiaries by expeditiously addressing individual cases, such as beneficiary complaints, provider issued notices of noncoverage, and EMTALA (Emergency Medical Treatment and Active Labor Act) "dumping" violations.
- Educate physicians and providers on the review process and quality of care expectations.
- Educate and advise Medicare beneficiaries on their rights under the law.
- Provide a process to address quality of care concerns filed by medicare beneficiaries or family caregivers.
Why you would call IPRO
If you have questions, concerns or complaints about a hospital stay denial, or have questions or concerns about the treatment you received from a doctor, hospital or health care provider, you may call the IPRO Helpline at 1-800-331-7767.
If you are hospitalized and feel that you are being asked to leave before you feel you are able, you have the right to "appeal" that decision by your hospital.
You may call IPRO to intercede, review and respond. These calls are handled promptly to provide you with necessary information for your continued care.
QIO help lines will answer questions on beneficiary rights, quality of care issues and preventive health measures.
If you have questions about your rights as a patient, you may call the IPRO Helpline at 1-800-331-7767.
If you have questions about Medicare, your benefits and entitlements, or suspect you have been a victim of fraud or abuse, call 1-800-MEDICARE (1-800-633-4227) English or Spanish, TTY 1-877-486-2048 or visit www.Medicare.gov
Consumer Protection Reviews
Anti-Dumping - The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted to prevent discrimination in transferring, discharging, or refusing to treat patients coming to the emergency department. While the Act applies to all Medicare participating hospitals, it protects anyone coming to a hospital seeking emergency medical services, not just Medicare beneficiaries. IPRO receives EMTALA cases for review after The Centers for Medicare & Medicaid Services (CMS) has made a determination that a violation has occurred. IPRO functions as a medical consultant to the Office of Inspector General prior to the application of a civil monetary penalty. IPRO physician consultant review focuses on four areas in assessing the services provided:- Existence of an emergency medical condition
- Provision of an appropriate medical screening examination
- Stability of patient for discharge/transfer
- Appropriateness of transfer and appropriate communications between sending and receiving hospitals.
More About IPRO
IPRO also provides the following health care assessment and improvement services for federal and state agencies, health care providers, managed care organizations, commercial insurers, Fortune 500 corporations, business coalitions and unions:
- Utilization review and quality assurance
- Quality improvement study design
- Data collection, abstraction and analysis
- Retrospective claims review
- Independent review of health plans' decisions to deny, reduce or terminate care
- Encounter data validation
- Health Plan Employer Data & Information Set (HEDIS®) Compliance Audit™
- Consulting Services
- The Centers for Medicare & Medicaid Services (CMS)
- New York State Office for Aging - New York State Department of Health
- Health Insurance & Information Counseling Assistance Program (HIICAP)
- Empire Medicare Services
- GHI
- Health Now - Medicare Part B
- New York State Ombudsman Program
Speakers Bureau
Call (516) 326-7767, extension 262. IPRO professionals are available, cost free, to address senior citizen groups (50 or more) on a variety of health related topics including:
- How to get information about choosing nursing homes or home health agencies
- Medicare Updates
- Patient's Rights
- Appeal Rights
- Discharge Planning
Publications
IPRO produces and provides free literature about Medicare, Managed Care, Hospital Patient's Rights, Discharge Planning Rights, How to Choose a Nursing Home or Home Health Agency, and illnesses common to senior citizens. To be placed on our mailing list, please call the IPRO Communications Department at (516) 326-7767, extension 262.
1979 Marcus Avenue
Lake Success, NY 11042-1002
(516) 326-7767
Fax: 516-326-2310
Medicare Helpline: 1-800-331-7767TTY 516-326-6183
www.ipro.orgThis material was prepared by IPRO under a contract with the Centers for Medicare & Medicaid Services (CMS). The contents do not necessarily reflect CMS policy.
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