QASP.pdf

Quality Assurance Surveillance Plan

PERFORMANCE

REQUIREMENT

PERFORMANCE

STANDARD AND

ACCEPTABLE

QUALITY LEVEL

(AQL)

MAXIMUM

ALLOWABLE

DEGREE OF

DEVIATION

FROM

STANDARD

METHOD OF

SURVEILLANCE

POSITIVE AND

NEGATIVE

INCENTIVES FOR

NOT

MEETING AQL

Medical and

Dentistry

Specialist

Selection

The Contractor adheres to the established medical specialist qualifications and selection criteria as appropriate on a case-by-case basis. Screening includes:

Professional licensure

• Board certified (ABMS) and no sanctions placed on license prior to assigning a case file.

• Good standing with medical board specific to practice.

• Active license in the specialty or subspecialty requested.

Conflict of interest

• No financial affiliation or any conflict of interest with the provider in the disputed claim being reviewed.

• Specialist has not previously reviewed the case for another business entity.

HIPAA

• Contractor’s staff and assigned specialist must be compliant with

HIPAA requirements.

• Acknowledgement of

HIPAA requirements must be documented prior to each assignment.

No Deviation 100% performance review of each

Medical Review

Analysis/Special

Project

Performance reviewed at quarterly meetings

Incentive: Outstanding performance review at the end of the contract period for meeting all mandated performance requirements.

Disincentive:

Less than satisfactory performance review at the end of the contract period for not meeting all mandated performance

Unsatisfactory will be subject to nonpayment and may result in not exercising the next option at the end of the year.

Medical Review

Analysis Format

The Contractor will provide deliverables in accordance with the established OPM format or the Contractor’s format that has been approved by OPM.

No Deviation 100% performance review of each

Medical Review

Analysis

Incentive: Outstanding performance review at the end of the contract period for meeting all

REQUIREMENT

PERFORMANCE

STANDARD AND

ACCEPTABLE

QUALITY LEVEL

(AQL)

MAXIMUM

ALLOWABLE

DEGREE OF

DEVIATION

FROM

STANDARD

METHOD OF

SURVEILLANCE

POSITIVE AND

NEGATIVE

INCENTIVES FOR

NOT

MEETING AQL

The Contractor will maintain the ability to provide these deliverables in a secure electronic HIPAA compliant format in addition to ad hoc traditional hard copy capability.

Performance will be reviewed at designated meetings performance review at the end of the contract period for not meeting all mandated performance will be subject to nonpayment and may result in not exercising the next option at the end of the year.

Analysis

Each Medical Review

Analysis will include the following:

• Detailed Case Synopsis

(comprehensive with inclusion of patient specific clinical information from the medical record)

• Accurate assessment and clear, detailed and definitive response to each Medical Inquiry

Question(s) in accordance with Health

Plan definitions, utilizing the patient’s submitted clinical records.

• Credible medical/scientific literature and clinical practice guidelines cited to support determinations.

• Provision of all aforementioned references upon written request for medical and dental case reviews.

• Contractor’s medical director verifies the

No Deviation 100% performance review of each

Medical Review

Project.

reviewed at designated meetings or ad hoc.

Incentive: Outstanding performance review at the end of the contract period for meeting all performance review at the end of the contract period for not meeting all mandated

Analysis will be subject to nonpayment if rejected for quality.

An Incomplete

Analysis will be subject to a 50% reduction in payment of the established flat fee.

subject to nonpayment.

PERFORMANCE

STANDARD AND

ACCEPTABLE

QUALITY LEVEL

(AQL)

MAXIMUM

ALLOWABLE

DEGREE OF

DEVIATION

FROM

STANDARD

METHOD OF

SURVEILLANCE

POSITIVE AND

NEGATIVE

INCENTIVES FOR

NOT

MEETING AQL

consistency of medical advisory opinions with prior and/or similar medical opinions rendered (when a standard of good medical practice has changed, the medical review acknowledges the change and appropriate references are cited and provided in electronic copy- upon written request).

• Typed medical review analysis with no grammatical errors and typos.

• Contractor’s medical director acknowledges acceptance of review advisory decision and will be available to discuss concerns with OPM’s

COR as needed or assigned medical review staff.

Consultation

Services and

Special Projects

• Each Consultation

Service/Special Project report will accurately reflect the current nationally accepted standards of clinical practice:

• Credible medical/scientific literature and clinical practice guidelines cited to support determinations.

• Provision of all aforementioned references for the total references cited in excess of ten references, a mutually agreed upon number of references will be submitted with the reviewers report.

No Deviation 100% performance review of each

Medical Review

Project.

reviewed at designated meetings or ad hoc.

Incentive: Outstanding performance review at the end of the contract period for meeting all performance review at the end of the contract period for not meeting all mandated

Rejected for quality

PERFORMANCE

STANDARD AND

ACCEPTABLE

QUALITY LEVEL

(AQL)

MAXIMUM

ALLOWABLE

DEGREE OF

DEVIATION

FROM

STANDARD

METHOD OF

SURVEILLANCE

POSITIVE AND

NEGATIVE

INCENTIVES FOR

NOT

MEETING AQL

• Consultation

Service/Special Project medical advisory opinion is consistent with prior and/or similar medical opinions rendered (when a standard of good medical practice has changed, the medical review acknowledges the change and appropriate references are cited and provided as noted above).

• Contractor’s medical director must be available as expert witness to discuss advisory opinions via teleconferences or in person when legal suits are addressed with OPM on cases reviewed while under the contract.

An Incomplete Medical

Review

Analysis/Special

Project will be subject to a 50% reduction in payment of the established flat fee.

Quality of

Deliverable

Product

The Contractor will maintain a 100% satisfactory quality level of performance for all deliverable products.

No Deviation 100% performance review with written report submission as noted in the

Quality Control

Section below.

Incentive: 100% payment of the established flat fee.

The deliverable product will be subject to nonpayment as noted above.

Timeliness of

Deliverables

The contractor will deliver

100% of all deliverable written products and their supporting medical records/accessories in accordance with the established timelines:

• Seven (7) business days from receipt of case file for routine medical and dental reviews.

• Three (3) business days from receipt of case file for expedited/priority medical and dental reviews.

No Deviation without prior approval from the COR

100% performance review

Incentive: Outstanding performance review at the end of the contract period for meeting all performance review at the end of the contract period for not meeting all mandated requirements

PERFORMANCE

STANDARD AND

ACCEPTABLE

QUALITY LEVEL

(AQL)

MAXIMUM

ALLOWABLE

DEGREE OF

DEVIATION

FROM

STANDARD

METHOD OF

SURVEILLANCE

POSITIVE AND

NEGATIVE

INCENTIVES FOR

NOT

MEETING AQL

• When requested, cited references will be submitted to OPM within one (1) to two (2) business days following

Government request.

• The contractor will return all medical and dental review responses to OPM via secure FDC

System no later than

4:30 p.m. on the due date.

• The contractor and OPM will decide on a reasonable work order pickup and return time for consultation services or special projects.

Expedited reviews that do not meet timeliness guidelines are subject to nonpayment.

Routine reviews not meeting established timeliness with prior notification and acceptance by the COR will be subject to a

75% reduction in payment from the established flat rate if delivered within 1-2 business days. A 50% reduction in payment from the flat rate will be assessed if late greater than 2 business days at the discretion of the COR

Conflict of

Interest (COI)

Disclosures

The Contractor will implement a process to check for financial and other forms of conflict of interest including business or personal relationships and previous review services with other FEHB or PSHB carriers or regulatory bodies.

The Contractor will obtain a signed conflict of interest disclosure/attestation from each review prior to submitting the response to

OPM.

No Deviation 100% performance review of each

Medical Review

Project quarterly meetings

Incentive: Outstanding performance review at the end of the contract period for meeting all performance review at the end of the contract period for not meeting all mandated

Rejected for COI

A 50% reduction in payment from the flat rate will be assessed for replacement reviews required as a result of COI.

PERFORMANCE

STANDARD AND

ACCEPTABLE

QUALITY LEVEL

(AQL)

MAXIMUM

ALLOWABLE

DEGREE OF

DEVIATION

FROM

STANDARD

METHOD OF

SURVEILLANCE

POSITIVE AND

NEGATIVE

INCENTIVES FOR

NOT

MEETING AQL

Quality Control The Contractor will maintain a database for OPM that tracks Medical Reviewers, Medical

Reviews and Special

Projects for the following minimum parameters:

• Maintain current list of all medical specialties and the number of active reviews in each category.

• A minimum of three reviewers in each specialty must be available.

• Individual medical specialist activity for

OPM:

- Number of cases reviewed by category

(Routine and Expedited/

Priority)

- Number of cases rejected for quality issues or timeliness issues

- Corrective action taken for all rejected cases and timeliness issues

• Medical

Reviews/Special

Projects by specialty or case topic.

• The Contractor will provide monthly quantitative reports.

• The Contractor will submit quarterly written

Quality Control Reports to include the efforts of the Quality Review

Team and trends observed by the Medical

Director; unless otherwise directed by the COR.

The contractor’s designated medical specialist and nurse

No Deviation without prior approval from the COR

Quarterly Quality

• Control Review written report unless otherwise directed by the

COR.

Weekly teleconferences and/or meetings with OPM during the first quarter of the base period.

Then monthly or more frequently at the discretion of the COR

Dontractor’s designated medical specialist and nurse must be available for teleconferences, as needed, to discuss quality concerns weekly, monthly, or quarterly, as determined by

OPM.

designated meetings and scheduled quarterly meetings.

Incentive: Outstanding performance review at the end of the contract period for meeting all

Disincentive: Less than satisfactory performance review at the end of the contract period for not meeting all mandated performance rating may result in not exercising the next option at the end of the contract year.

PERFORMANCE

STANDARD AND

ACCEPTABLE

QUALITY LEVEL

(AQL)

MAXIMUM

ALLOWABLE

DEGREE OF

DEVIATION

FROM

STANDARD

METHOD OF

SURVEILLANCE

POSITIVE AND

NEGATIVE

INCENTIVES FOR

NOT

MEETING AQL

must be available for teleconferences, as needed, to discuss quality concerns, as determined by OPM.