Quality Assurance (QA) Plan

7.1.2.7 - Quality Assurance (QA) Plan (Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15) In each element of the IPRS, the MAC shall incorporate quality assurance (QA) activities. The QA activities ensure that each element is performed consistently and accurately throughout the MAC’s MR program. The MAC shall have in place continuous quality improvement procedures. Quality improvement procedures use information yielded from quality assurance methods and allow the MAC to analyze the outcomes from their program and to continually improve the effectiveness of their processes. The QA process shall include effective consultations between MR, POE, and other components, as appropriate, to ensure that duplicate efforts are not being undertaken. The QA process shall inform the MAC if claims subject to MR activity are consistently overturned on appeal. An effective QA process shall include regular meetings with other operational areas, including data analysis, policy development, POE, and appeals. Because the MAC is tasked with evaluating their MR program activities, it is necessary to establish QA activities that include thresholds and time limits for the MAC to assess their MR operations that ultimately improve the IPR. Examples include, but are not limited to: • Data analysis • Educational interventions • Inter-Rater Reliability (IRR) for MR licensed health care professionals and certified coders participating in medical review o Define acceptable IRR rates and actions taken for not meeting those acceptable rates • Accuracy of medical review decisions o Define acceptable accuracy rates and actions taken for not meeting those acceptable rates • Overturn rate on appeals • Cost of review • Edit effectiveness