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Quality Management (QM) program - Chapter 14, 2021 UnitedHealthcare Administrative Guide

The QM program helps ensure access to health care and services with a review using established quality improvement principles.

We use our QM program to:

  • Identify the type of care and services given
  • Use clinical guidelines and service standards to monitor clinical performance
  • Review the quality and appropriateness of services given to our members
  • Review the medical qualifications of participating health care professionals
  • Continue to improve member health care and services
  • Improve patient safety and confidentiality of member medical information
  • Resolve identified quality issues

Our board of directors oversees the QM program. The Vice President of Quality and Chief Medical Officer are in charge of day- to-day QM operations.

Committee structure for Medicare and Commercial product lines may include the following:

The Medical Advisory Committee (MAC) oversees, reviews and provides recommendations on QM activities. These include:

  • Clinical indicators monitoring
  • Analysis of potential/actual barriers to improve clinical performance
  • Medical policies
  • Pharmacy updates
  • Service standards

This committee suggests quality improvement activities based on a review of potential/actual barriers to improving clinical performance found in their regions. They create and implement regional components of the QM work plan.

The Regional Quality Oversight Committee (RQOC) oversees these quality improvement activities.

When there are significant concerns about quality of care, the Regional Peer Review Committee (RPRC) is a forum for physicians to investigate, talk about and take action on these cases. The RPRC can make decisions on behalf of the National Peer Review and Credentialing Policy Committee (NPRCPC).

The NPRCPC is a forum for physicians to talk about and take disciplinary action on member cases involving quality of care concerns that were unresolved through Improvement Action Plans administered by the RPRC.

The National Practitioner Sanctions Committee (NPSC) is a place for physicians to discuss and act on sanction reports about compliance with our credentialing plan and/or patient safety concerns. Sanctions related to Licensed Independent Practitioners are monitored by government agencies and authorities. These include:

  • Centers for Medicare & Medicaid Services (CMS)
  • Medicaid agencies
  • State licensing boards
  • The Office of the Inspector General within the federal Department of Health and Human Services.

The QM program:

  • Identifies high-volume and/or high-risk areas of care and service affecting our members.
  • Develops clinical practice guidelines for preventive screening, acute and chronic care and appropriate drug usage. These are based on available national guidelines.
  • Identifies clinical areas for quality improvement activities using claims and other data analyses. These include frequency and cost breakdown by member’s age, sex and line of business. It also includes groupings like episode treatment groups, major medical procedure categories and diagnosis-related groups (DRGs).
  • Reviews preventive care delivered using health care audit results.
  • Surveys members, care providers and employers to track satisfaction and reason for voluntary care provider disenrollment.
  • Measures results against physician service standards like wait times for appointments, in-office care, practice size and availability. We use information from members, Consumer Assessment of Healthcare Providers and Systems (CAHPS) member survey information and GeoAccess analysis.
  • Checks to help ensure providers perform QM-related activities as our contracts require.
  • Audits records to see if medical record standards and preventive care guidelines were met.

Note: This is not the only reason we audit medical records. Other audits may have different purposes and processes.

  • Helps to ensure medical record documentation provides the plan for member care. This includes continuity and coordination of care with other physicians, facilities and health care professionals.
  • The RPRC and NPRCPC investigates and resolves member complaints about medical care and services. The investigation may include contact with the member, physician and/or other health care professionals. It may also review medical records and your responses to potential concerns.