Selected by CMS as the UPIC W 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, Hawaii, 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 UPIC SW 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.
The Investigations Medicare Integrity Contractor (I-MEDIC) as a task order (TO) under the Unified Program Integrity Contractor (UPIC) Indefinite Delivery Indefinite Quantity contract vehicle. The overall strategy for this five-year contract is to detect, prevent, and proactively deter fraud, waste, and abuse (FWA) in Medicare Parts C and D.
This work focuses primarily on complaint intake and response; data analysis; assessing leads from various sources; investigative actions; administrative remedies; referrals; and program integrity efforts related to potential FWA from prescribers, pharmacies, and beneficiaries. The I-MEDIC team coordinates with staff from the Centers for Medicare & Medicaid Services (CMS), CMS contractors, and other stakeholders to accomplish their goals. 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).
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. In 2018, CMS split the NBI MEDIC into two contracts: NBI MEDIC and Investigations MEDIC. The NBI MEDIC continues its efforts in plan sponsor oversight and data analytics. For request of information and submission of complaints please refer to the I-MEDIC Contract for details and forms.
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 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 IPRO Quality Improvement Organization (QIO) which includes Delaware, Maryland, District of Columbia, Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York, New Jersey, and Ohio. 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 this QIN-QIO, Qlarant is dedicated to transforming health care and health care outcomes for patients. 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
- Immunization resources
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.
Maryland, District of Columbia, West Virginia, North Dakota
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.
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.
The Centers for Medicare & Medicaid Services (CMS) awarded a contract to help clinicians in small practices in Maryland and the District of Columbia prepare for and participate in the new Quality Payment Program, established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
This technical assistance, authorized and funded under MACRA, brings direct support to an estimated 5500 Merit-based Incentive Payment System (MIPS) eligible clinicians in small practices with 15 or fewer clinicians, including small practices in rural locations, health professional shortage areas, and medically underserved areas across the country. The direct technical assistance is available immediately, free to all MIPS eligible clinicians, and will deliver support for up to a five-year period.