May 21, 2025
Checks and balances ensure programs, systems, and organizations function as expected and meet standards and quality expectations. As a joint federal and state program, Wisconsin Medicaid supports more than one million Wisconsin residents with high-quality health care coverage, long-term care, and other services that promote physical and mental health well-being. MetaStar reviews health care records to provide checks and balances in quality of care as well as payment and billing.
Melissa Erickson
Melissa Erickson is the Fee-for-Service Project Manager in the External Quality Review (EQR) Department. Erickson’s healthcare experience spans over 30 years as a registered nurse with experience in medical surgical (med surg), obstetrics (OB), emergency (ED), infection prevention, and employee health. Before joining MetaStar, she was a Chief Nursing Officer for 10 years. She uses that expertise with a team of three nurse reviewers, a medical records coordinator, a project coordinator, and several physician reviewers to perform retrospective reviews, primarily of inpatient hospital stays funded by Medicaid. The Wisconsin Department of Health Services (DHS) contracts with MetaStar to complete the reviews, which ends up being about 7,000 medical records reviewed per year.
The Selection Process
Wisconsin DHS provides MetaStar with Medicaid-paid claims from the state for inpatient hospital stays. MetaStar uses claims data to randomly select records to review. MetaStar’s Department of Information Technology (IT) built a customized tool for this work. The tool allows Erickson and the team to select the records to review, track, and view progress.
At the start of the review year, Jenny Klink, vice president of EQR, determines how many of each selection type to complete based on the goals and objectives of DHS. All reviews focus on inpatient cases within the Medicaid population. Selection types include:
- Focused OB: Reviews related to childbirth and the inpatient care provided to the mother.
- High Utilization: Inpatient stays involving conditions like sepsis, pneumonia, shortness of breath, unspecified chest or abdominal pain, altered mental status, or fever – these typically require a significant number of resources for care.
- Institution for Mental Disease (IMD): Inpatient care at a facility classified as an IMD for members under 21 years old.
- Newborn Readmission: A newborn is readmitted to the hospital within seven days after being discharged from their delivery stay.
- Substance Use Disorder: An individual admitted with a primary diagnosis of substance use disorder.
- Mental Health: Admissions where the main diagnosis is related to a mental health condition.
- Readmission: An inpatient hospitalization that occurs within 31 days of a previous inpatient discharge. Both hospital records are reviewed.
- Short Stay: Inpatient admissions that stay for less than three days.
“One main question I get from the hospitals is why are you reviewing a medical record that’s so old,” shared Erickson, “It’s because the hospitals have a year from the date of discharge to get adjustments and to submit claims for payment; they are still active. So, we don’t pull records unless they are over a year old from the date of discharge.”
Erickson explains, “We do six selections in the year. Basically, what happens is we look at all the claims and randomly select records based on the criteria for that specific selection type.” Each selection period includes all selection types, and the number of selections is based on the DHS contract.
Erickson inputs the numbers of each selection type into the tool. The tool then randomly selects the records based on the selection type and number needed.
The Review Process
Once a claim is selected, MetaStar contacts the hospital and requests the record. The hospital uses another custom tool created by MetaStar to securely upload the record so the team can begin the review process.
The reviewers validate that the medical record submitted by the hospital matches the days of service, patient name, date of birth, and other details on the claim record provided by DHS.
The records are reviewed by nurse reviewers. “Each reviewer uses the same reviewer guidance to ensure consistency,” shares Erickson, “They review the overall care provided to ensure standards of care were met, along with appropriate utilization of resources and accurate coding of the record.”
Sometimes, reviewers escalate the review to an outside medical coding company, Elevate Medical Solutions (Elevate). This happens when the nurse reviewer finds that the care doesn’t match or align with the diagnosis and procedure codes. The coding experts at Elevate review the record to ensure accurate coding.
The reviewer also looks for any concerns related to the quality of care. “The nurse reviewers check to see if care is medically necessary, reasonable, and appropriate for diagnosis and condition. And then on the readmission selections we’re looking at, were they discharged prematurely?” If there are quality issues, the record is referred to a physician reviewer whose area of specialty best aligns with the case. The physician reviewer can then determine if there is a quality-of-care concern.
If a quality-of-care concern is identified, MetaStar notifies the hospital by sending a preliminary findings letter. “We might not have all the information, sometimes we don’t get all the documentation because we get only what they send in.” Erickson explains, “An example is for focused OB, when we look at Rubella immunity sometimes they forget to send the OB prenatal labs because they were part of the clinic records.”
The review process includes opportunities for the hospitals to provide additional information to help the reviewer verify the record.
Outcomes From the Reviews
Recoupable events indicate the hospital must repay the Wisconsin Medicaid program. For example, if a hospital does not submit the record for review, it might be required to repay the full amount of the claim. If it was determined that the inpatient stay should have been an outpatient admission based on the care provided, it may be considered a recoupable event, and the hospital would return any overpayments to the State of Wisconsin. The total number of payment issues is a small percentage of the total records reviewed.
Another result of the reviews is identifying quality-of-care issues that do not involve any repayment but highlight areas for improvement in patient care. Nurse reviewers flag cases where guidelines of care weren’t followed or documented. In some instances, the hospital submits an improvement plan, and MetaStar’s team ensures the plan is carried out. “We want to work with [the hospitals] to help improve care,” said Erickson.
Recently, MetaStar nurse reviewers identified a trend in Focused OB cases. Guidelines from the American College of Obstetricians and Gynecologists (ACOG) have evolved from the standard six-week follow-up to an initial assessment within the first three weeks postpartum to address any acute postpartum issues. During the review process, MetaStar’s nurse reviewers found that most providers were not recommending a three-week follow-up at discharge; instead, only scheduling a routine six-week postpartum visit. Hospitals were informed of the quality-of-care concern and given updated guidelines to help address the issue. As a result, many hospitals took this concern to their obstetric committees and made the recommended change in follow-up care across their systems. MetaStar collaborated with organizations to submit performance improvement plans that incorporate the follow-up recommendations and will ensure these plans are being implemented during future reviews.
By identifying and helping to correct this trend, MetaStar contributes to improved outcomes for Wisconsin mothers and newborns during the postpartum period—a critical time for maternal and newborn health.
Improving Health for All
By conducting thousands of medical record reviews each year, MetaStar helps ensure Medicaid-funded care is appropriately billed, medically necessary, and delivered with the standards of care met. MetaStar proactively partners with health care providers to identify quality-of-care concerns and implement meaningful improvements. Through the leadership of experienced professionals like Erickson and the dedicated team of reviewers, MetaStar is helping to shape a healthcare system that is not only accountable but also improving care to meet the needs of Wisconsin’s Medicaid population.
Learn more about the other programs MetaStar supports through independent assessments.