Quality Improvement: Guidelines and Resources

Introduction: 

  • Medical Record Review (MRR) Standards have been adopted by the Health Options Quality Improvement/Utilization Management (QI/UM) Committee.
  • Medical Record Review Standards have been developed for:
  • The importance of having standards is to verify that Practitioners and Providers:
    • Are aware of the expected level of care and associated documentation.
    • Are aware of the requirements for maintenance of confidential medical information and record keeping.
    • Are assured that medical records are being evaluated in a consistent manner.

Goals:

  • The Quality Improvement/Utilization Management Committee has established the scoring standard of 80% for the Medical Record Review elements.
  • If the score of 80% has not been met for MRR, a follow–up review will be scheduled to assess improvement.
  • Practitioners and providers are notified of their results and any areas of deficiency by letter within forty-five (45) calendar days of the review.
  • Repeatedly failing to meet an overall performance score of 80% may lead to initiation of corrective action, up to and including termination from the Plan.

Frequency of Reviews:

  • Medical record reviews are conducted at least annually on a sample of PCPS, SCPs, and ancillary providers (e.g. Home Health Agencies, Skilled Nursing Facilities, and Behavioral Health Practitioners). Medical records for this review are obtained directly from the provider and may be reviewed at the provider’s location (on-site review) or sent to Highmark Health Options for a desk-top review.

Notifiable Diseases and Conditions:

The State of Delaware requires providers to report certain diseases, infections, conditions and outbreaks such as, but not limited to, chicken pox, lead poisoning, Lyme disease, and mumps . A full listing of notifiable diseases can be found at http://dhss.delaware.gov/dph/dpc/rptdisease.html. This listing provides instructions for reporting and includes those conditions identified as “rapidly” reportable to the Delaware Division of Public Health.

[1] Delaware Administrative Code, 16 DE Admin Code 4202 Control of Communicable and Other Disease Conditions, Section 2.0