Selected by CMS as the W UPIC in 2017, Qlarant is performing fraud, waste and abuse detection, deterrence and prevention activities for Medicare and Medicaid claims within the Western Jurisdiction for the states* of Alaska, Arizona, California, Idaho, Montana, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming (*other territories of the Western Jurisdiction to include American Samoa, Northern Marianas Islands and Guam).
Selected by CMS as the SW UPIC in 2017, Qlarant is performing fraud, waste and abuse detection, deterrence and prevention activities for Medicare and Medicaid claims for CMS within the Southwestern Jurisdiction for the states of Colorado, New Mexico, Oklahoma, Texas, Arkansas, Louisiana and Mississippi.
CMS originally awarded the National Benefit Integrity (NBI) MEDIC contract to Qlarant in 2005. In 2007, the MEDIC contract was awarded to Qlarant for regional Part C and D investigation services. In 2009, CMS again assigned responsibility to Qlarant to serve as the NBI MEDIC in all fifty states and Puerto Rico. As the MEDIC, Qlarant monitors the prescription drug program and investigates beneficiary complaints and leads for potential fraud, waste and abuse related to Medicare prescription drug benefits. Part of Qlarant’s solution for fighting fraud, waste and abuse is comprehensive data analytics and trend analysis of fraudulent practices. One technology employed by the NBI MEDIC involves the use of Qlarants’ proprietary, advanced data analytics tool, “PLATO”.
Federal law enforcement agencies may submit a Request for Information (RFI) to obtain Medicare Prescription Drug Event (PDE) data. Use the following HIPAA compliant for in lieu of Program Integrity Manual (PIM) exhibit 25 (DOJ) or Exhibit 37 (OG).
Qlarant has been providing claims fraud investigation services for CMS as the Zone 4 ZPIC since 2008 in the states of Texas, Colorado, Oklahoma and New Mexico. As the ZPIC, Qlarant is responsible for the analysis and investigation of Medicare claims data for Parts A, B, Durable Medical Equipment, Home Health and Hospice through advanced analytics and trend analysis of Medicare claims by the data analysts, the review of medical records by designated (claims analysts) nursing personnel and physicians, and the assignment of investigators to gather details on potential fraud, waste or abuse of Medicare fund dollars. In addition, Qlarant provides fraud, waste and abuse investigative and data analytic services for Medicare Fee for Service claims and dual eligibility claims for the Medi Medi program in the state of Texas. Qlarant’s work on the ZPIC contract will be transitioned into its work on the UPIC contracts.
In its 9th year as the MIC, Qlarant evaluates and subsequently audits potential fraud, waste and abuse of Medicaid claims dollars by beneficiaries and all types of providers in 6 of the 10 CMS Medicaid regions (34 states and D.C.). Qlarant utilizes investigators, nurses, CPAs and auditors, in close collaboration with all the states and the Medicaid Fraud Control Units, to examine Medicaid health claims and/or identify issues of medical necessity or appropriateness of care when the medical records of an individual or a provider are evaluated. In addition, the MIC performs extensive medical review across all medical specialties, conducts audits of paid Medicaid claims across all provider types and settings of care to find overpayments or potential fraud and generates an audit findings report that directly results in a recovery of money from a provider. Qlarant has developed a state mapping tool that contains information on eligibility and coverage for the 34 states in the MIC jurisdiction to facilitate reviews and evaluations. Qlarant’s work on the MIC contract will be transitioned into its work on the UPIC contracts.
Qlarant has been working with the State of Delaware since 2015 to establish innovative and effective approaches to Medicaid fraud, waste and abuse. To that end, Qlarant is utilizing PLATO to assist the State of Delaware in evaluating its paid Medicaid claims to identify probable fraud and/or misuse of Medicaid dollars. In addition, Qlarant is lending its expertise to train Delaware Medicaid employees on the use of the predictive modeling software to allow independent research of Medicaid claims and the selection of potential candidates (provider and/or beneficiary) for investigation by the State. The State of Delaware staff is also being trained by Qlarant in medical review strategies.
Qlarant is supporting the activities of IBM Corporation by providing Predictive Modeling subject matter expertise to support the National Fraud Prevention System (“FPS”) by implementing a Predictive Modeling System capable of identifying high-risk claims and an integrated case management system that manages the predicting modeling alerts to conclusion. As a part of the IBM team, the organization has provided extensive policy expertise to assist in the development of several models that have been highly successful in the FPS.
The State of Florida’s Agency for Health Care Administration (AHCA) contracts with Qlarant to provide quality assurance for the state’s Disabilities and Aging Services system. Our number one goal in Florida has always been to improve the quality of support for Florida’s citizens with developmental disabilities. We work in partnership with the Agency for Persons with Disabilities (APD) at the central office and each local area office. We actively promote individuals’ rights, choice, full inclusion, health and safety, respect and dignity and satisfaction with services and supports.
Qlarant, as a member of the Georgia Collaborative ASO, supports the State of Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) to improve the quality of support services for Georgia’s citizens with developmental disabilities. Our mission is helping people to live everyday lives through collaborative quality improvement strategies that promote a person-directed service delivery system. We hope to enhance the service delivery system with results that reflect the choices and preferences that people consider most important. Please visit the Georgia Collaborative ASO website to learn more.
Qlarant operates a statewide quality improvement project with the Virginia Department of Behavioral Health and Developmental Services. This contract is designed to assist the Commonwealth to evaluate the quality of the service delivery system for individuals with intellectual and developmental disabilities. Qlarant conducts Person Centered Reviews with individuals receiving services via interviews, observations and record reviews. Qlarant also directly evaluates the systems and performance of service providers through Provider Quality Reviews. Data collected from both review types are utilized to give feedback to DBHDS to support quality improvement initiatives.
Qlarant conducts interviews with individuals receiving state or waiver funded supports and services, using a variety of interview tools and techniques to gather experiences and opinions to evaluate quality. This information is used to assess the effectiveness of service delivery systems in meeting defined needs and generating individual’s desired outcomes. One interview tool used by Qlarant in multiple states is the National Core Indicators Adult Survey (NCI) developed by Human Services Research Institute (HSRI) in collaboration with the National Association of State Directors for Developmental Disability Services (NASDDDS).
The Qlarant team is expert in utilizing the NCI tool with various populations served through the following state service programs:
- Aging and Disabled
- Intellectual Disabilities
- Disabilities and Aging
- Head and Spinal Cord Injuries
Our trained staff schedules interviews at convenient times for the individuals being interviewed. Interview environments are individualized to account for unique communication styles and needs. Findings are compiled, analyzed and reported in a timely and confidential manner. Qlarant is recognized by the Centers for Medicare and Medicaid Services as a QIO-like organization, enabling states to obtain a federal match for these quality improvement related activities.
Qlarant is part of the Atlantic Quality Innovation Network (AQIN) Quality Improvement Organization (QIO) which includes the District of Columbia, New York and South Carolina. Beginning August 1, 2014, the network was tasked with implementing strategies to facilitate quality improvement throughout these regions. The AQIN aligns with the DHHS National Quality Strategy, the CMS Agency strategy goals including: better care, better health and lower costs (Triple Aim), prevention and population health, expanded health care coverage and enterprise excellence. Four foundational principles include: eliminating disparities, strengthening infrastructure and data systems, enabling local innovations and fostering learning organizations.
As part of the AQIN, Qlarant is dedicated to transforming health care and health care outcomes for patients in the District. Over the next 5 years (August 2014 – July 2019), our work will focus on several key quality improvement tasks including:
- Cardiac health and disparities in physician practices and Home Health Agencies
- Diabetes care and disparities through self-management
- Antibiotic stewardship
- Healthcare acquired nursing home conditions
- Care coordination to reduce admissions, readmissions and adverse drug events
- Clinician Quality Payment Program technical assistance
- Special Innovation Projects
- System-wide quality improvement initiatives from case review contractor referrals
Throughout our QIN-QIO work we will utilize results-oriented improvement approaches: use data to determine interventions that will be effective, involve patient and family at all phases of improvement efforts, focus on system-level interventions that can be sustained, use learning and action networks to convene stakeholders for large scale improvement and use technical assistance and coaching when needed.
In the fourth year of the 11SOW for the District of Columbia, we completed a successful CMS monitoring visit and timely deliverable submissions. Visit the AQIN website for more information.
Maryland, District of Columbia, West Virginia, North Dakota, North Dakota CHIP
Federal regulations require that states operating Medicaid managed care programs contract with an independent External Quality Review Organization (EQRO) to assess the quality, access and timeliness of health care services provided to Medicaid beneficiaries enrolled in managed care organizations (MCOs).
Mandatory External Quality Review (EQR) Activities
- Review of MCOs to determine compliance with federal and state requirements
- Validation of MCOs’ performance measures
- Validation of MCOs’ performance improvement projects
- Validation of MCOs’ network adequacy (new)
- Annual Technical Report on the quality of, access to, and timeliness of healthcare and services for Medicaid enrollees
Optional EQR Activities
- Validation of encounter data
- Validation of consumer surveys
- Calculation of performance measures
- Development of performance measures
- Conduct performance improvement projects
- Conduct focused clinical and non-clinical studies
- Readiness review of new MCOs
EQRO — Living the Mission
The External Quality Review Team identifies opportunities for improvement and recommends interventions that address barriers and aim to improve performance. For example, based on recommendations provided by the EQR Team, one ND MCO improved compliance in its Well-Child Visits in the 3rd, 4th, 5th and 6th Years of Life performance measure. Results improved from 34% compliance to 52% compliance—an 18 percentage point improvement.
Qlarant represents the District of Columbia’s Department of Health Care Finance (DHCF) conducting comprehensive face-to-face assessments to determine if Medicaid beneficiaries are eligible to receive home and community-based services, and discern their level of need.
Long-Term Care (LTC) Services—LTC services help people with a chronic illness or disability meet health or personal needs. LTC services can be provided at home or in the community, a nursing home or another facility. A person may need them for a short period of time after an acute illness or hospitalization, or they may need them over several months or years. People may receive these services in their home under one of the Home and Community-Based (HCBS) Waivers. HCBS waivers are special programs that provide LTC services that help Medicaid eligible individuals live in the community and avoid institutionalization. Currently Qlarant assesses the need for two service types :
- Personal Care Aide (PCA) services assist people with activities of daily living, such as dressing, bathing, eating and toileting.
- Adult Day Health Program, 1915i (ADHP) is a new service under the HCBS State plan option. This service is designed to encourage adults 55 years and over, with a chronic condition, to live in the community by offering non-residential medical supports; supervised therapeutic activities in an integrated community setting that fosters opportunities for community inclusion and to deter most cost facility-based care.
Referral requests are received electronically and evaluated for completeness, accuracy and Medicaid eligibility. Those that can be processed are then entered into Qlarant’s Blue Crab software program to initiate the review process. A nurse contacts the beneficiary, completes a face-to-face assessment and documents the results in Blue Crab. The overall documentation is validated, and after approval, the results are then shared with the beneficiary and the associated physician and designated provider of services.
Qlarant processes an average of 960 referrals monthly, excluding those that were received and unable to be processed due to being incomplete for various reasons.
Communication and Customer Service
- Routine communication with the client is conducted through face-to-face meetings and conference calls.
- Qlarant has a dedicated LTC email to address issues, questions, concerns and accolades by the client and providers. This mailbox is monitored by a dedicated employee and responses are provided within 24 hours or the next business day.
- Qlarant also has a dedicated Personal Service Line to address the increases in volume of calls received daily. This line is monitored and answered in accordance with our policy. We receive over 3,500 calls /month.
- Our staff attends the monthly DC Medicaid State Plan and EPD Waiver provider meetings to maintain communication with the client, home health agencies and stakeholders.
- The DC LTC team has reviewed/revised all work processes and work instructions, adding checklists, to ensure completion of all aspects of the review process.
- Patterns/trends with field nurse review issues identified areas for increased training to ensure accuracy of documentation.
- QA review processes were revised to include QA of letters prior to dissemination.
Fraud, Waste and Abuse (FWA)
- A comprehensive quality assurance (QA) review process monitors the initial intake process, nurse assessment completion and letter completion.
- The QA process for intake and 100% review of the assessed cases completed by field RN assessors and the associated letters has resulted in improved accuracy and quality of the intake information, assessments, and more consistent, congruent and standardized documentation.
Despite efforts to address health disparities, low-income and racial and ethnic minority populations continue to face significantly worse quality of care in some areas of focus with gaps in health equity. The CMS Office of Minority Health (OMH) is focused on improving health care quality and health outcomes among Medicare and dually eligible minority and underserved populations; which aligns with the CMS’ Quality Strategy—Supporting Goals in a way that eliminates health disparities. CMS OMH has contracted with NORC to develop a 5-year CMS Equity strategic plan to infuse disparity reduction efforts in CMS programs.
We utilize our subject matter expertise in health disparities, and Quality Improvement (QI) science to guide NORC is assisting CMS OMH to reduce health care disparities and improve health equity in CMS Medicare programs.
NCD 3.0 CONTRACT
Since 2011, the CMS has funded one of the largest national hospital patient safety programs called the Partnership for Patients (PfP), which has a goal of making hospital care safer by preventing hospital-acquired conditions and improving care transitions to reduce avoidable readmissions. This program is in its 3rd scope of work (2016-2019) and is now called PfP 3.0. Hospital Improvement Innovation Networks (HIINs), who are comprised of organizations like the American Hospital Association, State Hospital Associations, Premier and other large health systems, are funded to provide technical assistance and expertise to 4,000 hospitals nationwide to achieve quality measurement goals and reduce hospital harm. The National Content Developer (NCD) is the coordinating center for the PfP and the HIINs.
This aims of this CMS campaign/project are carried out by:
- HIIN/Hospital Learning collaboratives
- Intensive weekly training programs
- Establishment & implementation of systems to track & monitor hospital data and progress
- Identification of high performing hospitals to serve as coaches to lower performing hospitals
- Numerous National Affinity Groups to act as incubators to surface & spread innovation
PfP Patient Safety Areas:
- Catheter Associated Urinary Tract Infection (CAUTI)
- Catheter Associated Blood Stream Infection (CLABSI)
- Pressure Ulcers
- Injuries from Falls and Immobility
- Ventilator Associated Events
- Adverse Drug Events
- Surgical Site Infections
- Venous Thromboembolism
- Readmission Reduction
- Severe Sepsis and Septic Shock
- Hospital Culture of Safety
- Iatrogenic Delirium
- Clostridium Difficile (C. Diff.), including Antibiotic Stewardship
- Undue Exposure to Radiation
- Airway Safety
- Failure to Rescue
- Health Equity
Purpose — Qlarant’s Role
Qlarant works as a subcontractor to IMPAQ International (the prime) and leads/supports numerous national Affinity Groups for this campaign. Affinity Groups are made of Hospital Improvement Innovation Network (HIIN) leaders who have a vested interest in a certain patient safety topic and need a platform to:
- Surface and spread best practices and successful innovative hospital/health system efforts toward driving down patient harm—in rapid fashion
- Brainstorm specific barriers and challenges together
- Partner with federal and private partners to align efforts and bridge gaps
National Affinity Groups Topics
- Clostridium difficile and Antimicrobial Stewardship
- Health Equity
- Safety Across the Board
- Adverse Drug Events
- Launched 6 Affinity Groups at the start of the campaign with a continued sustained cadence and momentum
- Monthly preparation, coordination, development and support of Affinity Group participants and content
- All materials have been timely or exceeded expectations
Communication and Customer Service
- Weekly calls with client and daily emails
- Continued collaboration with client and CMS to ensure effective National Affinity Group activity for the Partnership for Patients