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Medica Administrative Manual > Provider Responsibilities > Participation in Reviews and Audits

Participation in Reviews and Audits

Medica expects its participating providers and subcontracted providers to deliver cost-effective, quality care. To measure ongoing performance, Medica providers are required to cooperate fully with quality assessment and improvement activities, audits and reviews as stated in the Medica Participation Agreement. These activities include, but are not limited to:

  • On-site visits or remote requests from Medica representatives for review of records, procedures and physical site.
  • Peer review as related to member complaints about quality of care.
  • Monitoring activities and focus studies to assess quality, utilization and cost of health services, whether required by Medica, or by state or federal regulators. 
  • Evaluation of clinical process and outcomes; reporting and monitoring through Healthcare Effectiveness Data and Information Set (HEDIS®). 
  • Review of inpatient utilization, including discharge planning and case management. 
  • Review of overall operations and compliance with National Committee for Quality Assurance (NCQA) standards and guidelines.
  • Other accreditation and/or state and federal regulatory requirements.
  • Corrective action plans as applicable.

In addition, participating providers are required to:

  • Provide access to electronic and/or photocopied medical records.
  • Submit quarterly aggregate reports to the Quality Improvement department of clinic-reported member complaints that relate to quality of care or service administered (MN providers only).

Selection process

Clinics are randomly selected or every clinic may be included for certain surveys (e.g., site survey). Members are randomly selected using claim data. Member selection is based on member volume, specific diagnoses, procedures or treatments received in a specified period.


Regulatory audit

If Medica is notified in advance of a regulatory audit, a staff member will be available to meet with clinics to discuss the areas that will be audited.

Medica is held responsible by regulators for clinic activities and practices; therefore, Medica may be cited for deficiencies as a result of a clinic audit. Medica then works with the clinic to develop a corrective action plan that is acceptable to Medica, the clinic and the regulator.

These review entities may be involved in an audit:

  • Centers for Medicare & Medicaid Services (CMS)
  • Department of Labor (DOL)
  • Department of Commerce (DOC) 
  • State regulatory agencies or licensing boards

For more information about Medica’s quality improvement activities and studies, call Medica’s Provider Service Center at 1-800-458-5512.



 

REV 10/2021

Date: 1/28/2023 6:02:28 PM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01