Quality Assurance is monitored through auditing and examination procedures at the health plan company level and investigating individual enrollee Quality of Care complaints.
Quality of care examinations include evaluation of:
1. Quality Program – Including its quality assurance plan, work plan, quality studies and activities, organization and staffing, credentialing program, medical records management, delegated activities and quality of care complaints.
2. Internal Complaint and Appeal Program – Including checking its systems and conducting quality of care examinations on a scheduled basis to assess the quality and processes including its record keeping system for complaints and appeals. We also conduct on-site reviews of quality of care complaints. When a complaint raising quality of care issues has been submitted to the Department of Health, we direct the Managed Care Organization to conduct its own quality of care investigation. Upon completion, we visit the Managed Care Organization to review the complaint file. Our review is done to ensure that the investigation by the Managed Care Organization is complete, that all issues have been examined and documented, that corrective actions have been taken as necessary, that corrective actions are being monitored and are effective.
3. Availability and Accessibility of health services to Managed Care Organization enrollees, including the geographic location of providers, appointment scheduling, coordination of care activities, referrals, timely access to health services, access to emergency care, continuity of care, direct access to ob-gyn services and equal access to chiropractic services. As part of the quality of care examination, we conduct site visits to some participating providers to examine their compliance with applicable law and rules.
4. Utilization Review Program, including the entity’s standards, staffing, procedures and qualifications of reviewers. We also look at the entity’s prior authorization process and its system and procedures for appeals of utilization review denials.