Applicable to all states except NC
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:
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:
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:
Note: This is not the only reason we audit medical records. Other audits may have different purposes and processes.