Leveraging Technology to Optimize Quality Assurance Strategies

Have you ever thought about the effectiveness of your quality assurance program? Do you use technology to execute best practices? The industry standards identify accuracy requirements by the Centers for Medicare and Medicaid Services (CMS). The technology needs to be intuitive  for the user to identify a multi-level sampling of your quality assurance program. The following are some examples of important multi-level areas of sampling:

  • Targeted high risk areas 
  • QA sampling of first pass coding
  • QA sampling of the auditor
  • QA sampling of the project 
  • QA sampling of regulatory changes, i.e. telehealth 

Federal regulations also state that MA organizations are responsible for the accuracy, completeness, and truthfulness of the data submitted to CMS for payment purposes and add that if any related entity, subcontractor, or contractor generates such data, that entity is similarly responsible (42 CFR § 422.504(l)).

CMS requires all submitted diagnosis codes to be documented on the medical record and to be documented as a result of a face-to-face encounter (the Manual, chap. 7 § 40). The diagnosis must be coded according to the ICD Coding Guidelines (42 CFR § 422.310(d)(1) and 45 CFR §§ 162.1002(b)(1) and (c)(2)-(3)).

Are you looking for additional Are you looking for additional guidance on these industry standards that are critical to quality assurance? Join us for a RISE Webinar on Wednesday, September 15th at 1:30pm EST.  During this webinar, we will demonstrate the use of technology to validate the effectiveness of your risk adjustment program. Click here to register today!  

Sources:
42 CFR § 422.504(l))
https://www.govinfo.gov/content/pkg/CFR-2006-title42-vol3/pdf/CFR-2006-title42-vol3-sec422-504.pdf

42 CFR § 422.310(d)(1)
https://www.ecfr.gov/cgi-bin/text-idx?SID=f0f245dfe58d524cc1a2218d652272e8&mc=true&node=se42.3.422_1310&rgn=div8

45 CFR §§ 162.1002(b)(1) and (c)(2)-(3))
https://www.ecfr.gov/cgi-bin/text-idx?SID=f0f245dfe58d524cc1a2218d652272e8&mc=true&node=pt45.2.162&rgn=div5#se45.2.162_11002

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