Quality Results Summer - 2017

 

Alerts and Reminders

Let’s Collaborate!

We want to work more closely with providers to find the most efficient way to deliver high-quality, cost-effective, patient-friendly healthcare. We recognize the challenges and pressures healthcare providers face. In an effort to be better practice partners, we want to explore success factors with you and solicit your feedback.

Topics we’ll explore include:

  • Medical home/neighborhood
  • Delivering/demonstrating value in the era of value based purchasing
  • The increasing burden of reporting clinical outcomes
  • Opportunities to optimize utilization and the promises/perils of genetic testing and other emerging technologies

Thank you for considering joining our provider engagement platform to discuss these topics. And thanks for letting us know how we can be better partners in helping your practice succeed!

To participate, send your email address to collaboration@qualchoice.com by June 30, 2017.

Please Submit Medical Records for IVA

To complete the Initial Validation Audit (IVA) in compliance with the Affordable Care Act (ACA), Complete Provider Resource will be contacting providers in July 2017. Complete Provider Resource will request member records with dates of service from January 1, 2016 to December 31, 2016. We appreciate your cooperation in this important time-sensitive request, per your plan agreement.

Most provider contracts do not require QualChoice or Complete Provider Resource to pay for copies of medical records. Please do not remit invoices for copy charges. Refer to your provider contract for specific details, usually outlined in Section 5.2 of your agreement.

Please direct any questions about this request to Complete Provider Resource at 501.223.2776.

Be Sure to Use In-Network Services

Contracted QualChoice providers are required to use in-network laboratory or pathology groups. Using out-of-network facilities violates your agreement with QualChoice and causes patients to pay significantly more for these services. When services are not available through an in-network provider, contact Care Management at 800.235.7111, ext. 7014 to submit an Out-of-Network Authorization Request. Learn more.

Denial of Coverage for Procedure Change

When a radiologist changes a member’s test or procedure and provides a service not requested by the ordering physician, coverage will be denied. In many instances, the ordering physician has already received pre-authorization for the ordered test. If you are uncertain which procedures must be pre-authorized, see Services Requiring Pre-authorization. For questions, please contact your QualChoice Provider Relations Representative at 800.235.7111.

Data Sharing to Prevent Fraud, Waste and Abuse

We are now submitting claims data to LexisNexis® Risk Solutions on a quarterly basis to be reviewed for fraud, waste and abuse. Results from this review may be used to:

  • Inform a provider about proper billing practices
  • Modify a Medical Coverage Policy
  • Recoup overpayments from a provider
  • Initiate disciplinary action

For questions, contact your QualChoice Provider Relations Representative at 800.235.7111.

Coverage Decisions

We work to make sure our members get the right healthcare in every care setting. We support proper care decisions based on medical necessity and the member’s specific health plan. When a service needs pre-authorization, our Medical Director and clinical staff follow QualChoice Medical Coverage Policies and the peer-reviewed and nationally noted guidelines of MCG Health, LLC. The clinical staff reviews:

  • Medical records or clinical documentation
  • Plan of care for the patient and services provided
  • Procedures, therapies, progress during hospital stay
  • Types and amounts of medicine given
  • Home services, equipment or follow-up appointments needed

We affirm the following:

  • Utilization management decisions are based only on what care and services are needed and the member’s coverage.
  • We do not reward providers or others for denying coverage of service or care.
  • We do not offer a financial bonus for under-utilization.