Quality Assurance (QA) and Quality Management (QM) program activities ensure that medical care and services meet clinical standards of quality. A payor’s QA program will include elements of peer review and audits of care, medical protocols, credentialing, and assessment of patient satisfaction. The overall goal is the delivery of high quality, cost effective care and to strengthen consumer confidence in accordance with the Consumer Bill of Rights and Responsibilities imposed by the Balanced Budget Act of 1997, 105 Pub. Law No. 33.
QA and QM programs are important for many reasons. One of which is that courts are increasingly holding managed care plans liable for negligent actions by physicians providing services to enrollees.
Excerpt from Errol J. King, Utilization Management & Quality Assurance in MANAGED CARE CONTRACTING HANDBOOK (2001).
Organizations such as the National Committee for Quality Assurance (NCQA) accredit health plans in the pursuit of improving the quality of healthcare. There are health plans in every state, the District of Columbia, and Puerto Rico that are NCQA accredited. Such plans cover 109 million Americans or 70.5% of all Americans enrolled in health plans. See http://www.ncqa.org/tabid/675/Default.aspx.
Over 90% of health plans use the Healthcare Effectiveness Data and Information Set (HEDIS) to measure performance on certain dimensions of care and service.