IPRO auditing HCFA’s project
Data validation will identify plan shortcomings
Up until the federal Balanced Budget Act set into motion external quality review of Medicare managed care contracts, quality improvement organizations (QIOs) were concerned that half their responsibilities were vanishing because they would no longer be a part of this review process. Private-sector review came out on top mainly due to vigorous lobbying by the American Health Quality Association (AHQA), the QIO umbrella.
The Health Care Financing Administration (HCFA) awarded two independent QIOs contracts to review the validity of the self-reported quality and utilization performance data provided by approximately 270 HMOs participating in Medicare. Validation of the processes by which the managed care organizations report data enables auditors to identify the plans’ limitations and establish baseline data for this first project.
Island Peer Review Organization (IPRO), in Lake Success, NY, was one of the two organizations chosen to audit the data for HCFA’s report. "This is first time HCFA has authorized an independent audit of the health plans," says Spenser Vibbert, director of corporate communications at IPRO. "It’s an important step in providing the five million Medicare beneficiaries with validated, consistent information they need to make informed decisions when choosing plans."
"More than 250 Medicare contracts reported HEDIS data," says Virginia Hill, vice president of the managed care department at IPRO. "We looked intensely at 60 of them by going on-site to see how they gathered, reported, and processed their data. While we were there, the facilities demonstrated their systems to us and showed us how claims are processed."
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