QUALITY MANAGEMENT

Continuing Quality Management

The IPA's Continuing Quality Improvement (CQI) program monitors and strives to improve the quality of patient care in both ambulatory and in-patient settings. AMM will be responsive to Health Plan requests for CQI studies, audits and inquiries regarding quality assurance on individual cases. With AMM guidance, the IPA's CQI Committee establishes criteria for acceptable quality care based on established standards and local practice patterns. AMM will assist the CQI Committee in identifying situations that fall outside the pre-established standards of practice set forth by regulatory agencies and as directed will set in motion corrective programs, such as physician and patient education. AMM will manage a program that will promote strict adherence to policies and procedures defined by the IPA and which comply with Health Plan, government and NCQA guidelines. The CQI program will deal the following issues:

  • Inappropriate use of ancillary services

  • Surgical complications

  • Poor medical record documentation

  • Inappropriate treatment plans based on diagnosis

  • Deaths within 24 hours of admission

  • Readmissions within 30 days for same or similar diagnosis

  • Cases involving member grievances and complaints

  • Physician profiles submitted by Coordinator

  • Cases involving potential malpractice litigation

AMM will assist in establishing a Retrospective Claims Review/Utilization Review system that will generate reports on a regular basis. These reports will focus on the individual provider and aggregate comparative analysis of services and fees by physicians, by specialty, and by patients in an effort to identify deviations in utilization patterns. AMM will assist in establishing corrective measures and policies to deal with cases falling outside the acceptable variance of established criteria.

AMM will recommend and assist in the development of logs (electronic and manual), which will be kept and maintained by the UR Committee, pertaining to denials for all inpatient and out-patient requests for authorizations. This log will be used on an ongoing basis to evaluate criteria and methodology of prior authorization, plus provide a tracking mechanism for the CQI program.