Quality Assurance Plan

7.3.3 - Quality Assurance Plan (Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15) The SAR shall include a narrative section titled Quality Assurance (QA) that describes the QA processes actually used since the submission of the previous IPRS. The QA process information includes, but is not limited to, descriptions for continuous monitoring/surveillance and improvement of the following processes: • How the MAC monitored the quality of reviews • Results of the IRR assessments of the MR licensed health care professionals clinical reviewers, and coders from the previous IPRS • How methods of data analysis were selected, validated and employed • How edit effectiveness was assessed for each prioritized problem (identify the MAC’s threshold for deeming an edit effective; discontinuing an edit) • How the MAC closely monitored the impact of MR activities and improper payment interventions specific to each problem on the prioritized problem list and their overall improper payment rate • How the MAC recorded improvement opportunities for their internal use • How any new processes were introduced to their MR business operations • Any other information the MAC believes is pertinent to their QA efforts The narrative information shall not include a restatement from the IPRS; rather, the QA section should be used to communicate the QA processes used since the submission of the previous IPRS as well as those planned for future months. The MAC shall also include an explanation for changes in problem priority, rationale for changes in workload or budget, or new initiatives directed by CMS that required the MAC to suspend activities described in the IPRS.