Quality Assurance and Performance Measurement
Quality Assurance is monitored through auditing and examination procedures at the health plan level and investigating individual enrollee Quality of Care complaints.
Quality of care examinations include evaluation of:
1. The Managed Care Organization's Quality Program Administration - Including its quality
assurance plan, work plan, quality studies and activities, organization
and staffing, credentialing program, medical records management,
delegated activities and quality of care complaints.
2. The Managed Care Organization's Internal Complaint and Appeal Program - Including
checking its systems and
conducting quality of care examinations on a scheduled basis to assess the
quality and processes including its record keeping system for complaints
and appeals. We also conduct on-site reviews of quality of care complaints. When a
complaint raising quality of care issues has been submitted to the
Department of Health, we direct the Managed Care Organization to conduct its own
quality of care investigation. Upon completion, we visit the Managed Care Organization
to review the complaint file. Our review is done to ensure that the
investigation by the Managed Care Organization is complete, that all issues have been
examined and documented, that corrective actions have been taken as
necessary, that corrective actions are being monitored and are
effective.
3. Availability and Accessibility of health services to Managed Care Organization
enrollees, including the geographic location of providers, appointment
scheduling, coordination of care activities, referrals, timely access to
health services, access to emergency care, continuity of care, direct
access to ob-gyn services and equal access to chiropractic services. As
part of the quality of care examination, we conduct site visits to some
participating providers to examine their compliance with applicable law
and rules.
4. Compliance with Minnesota's Utilization Review Law, including the
Managed Care Organization's standards, staffing, procedures and qualifications of
reviewers. We also look at the Managed Care Organization's prior authorization
process and its system and procedures for appeals of utilization review
denials.
Listed below are the most recent results from examinations for each health plan. To view each plan's report summary,
click on the health plan info button at the top of the page.
To view the PDF files, you will need
Adobe Acrobat Reader (free download from Adobe's website).
Most Recent Quality Assurance Reports:
- Blue Plus 2011 (PDF: 84.46 kb/ 25 pages)
- Group Health/HealthPartners 2009 (PDF: 62.70 kb/20 pages)
- IMCare 2009 (PDF: 87.76kb/ 25 pages)
- Medica 2012 (PDF:65.99kb/ 15 pages)
- MHP 2009(PDF: 82.32kb/ 23 pages)
- PreferredOne 2012 (PDF: 209.25kb/ 24 pages)
- Prime West 2011 (PDF: 381.33kb/ 18 pages)
- Sanford Health 2011 (PDF: 84.66 kb/ 17 pages)
- South Country 2009 (PDF: 88.03kb/ 25 pages)
- UCare 2011 (PDF: 83kb/ 20 pages)
To view other quality, HEDIS, enrollment or financial reports click here.
For more information, or to file a complaint, contact the MCS at 651-201-5100 or 1 800-657-3916.
