External Quality Review
HCE provides services to several state government programs and has an extensive internal network of professionals available to support programs wherever the services are conducted. HCE QualityQuest, a nonprofit subsidiary of Health Care Excel Inc., has been designated by the Centers for Medicare & Medicaid Services as a “QIO-like entity” capable of performing medical and utilization reviews.
QualityQuest has contracts with clients in several states to provide external quality-review services to evaluate managed care and prepaid inpatient health plans as required by the Balanced Budget Act of 1997.
Validating Performance-Improvement Projects
To achieve their objectives, performance-improvement projects must be designed, conducted and reported in a methodologically sound manner. HCE QualityQuest conducts quality-review activities to assess a health plan’s methodology for conducting a performance-improvement project, verify actual study findings and evaluate the overall validity and reliability of the study results.
Validating Performance Measures
QualityQuest analyzes the health plan’s accuracy of reported performance measures and adherence to established federal and state specifications. This review includes an evaluation of the process the health plan used to produce its performance measures.
Compliance Reviews
QualityQuest conducts compliance reviews of health plans to determine the quality, timeliness of and access to care and service provided to the plans’ members. Performance is assessed with regard to regulatory provisions and operational areas. We work closely with the plans and the state’s Medicaid agency during this process to ensure that an accurate evaluation is completed.
We have extensive experience with all components of compliance-review activities, including pre-onsite document review, onsite reviews, staff interviews, development of corrective-action plans, follow-up review activities to determine compliance with the corrective plans and preparation of required reports to the state agency.
