Risk Management
Healthcare managers identify and evaluate risks as a means to promote safety and quality with patients, staff members, and visitors within an organization. Risk managers work proactively and reactively to prevent incidents and minimize the damages post-sentinel event.
The Importance of Risk Assessments & Management Planning
Given that each organization faces unique challenges, there is not a one-model-fits-all risk management solution. QPI’s Chief of Quality and Risk Officer will identify your organization’s potential risk by completing a SWOT Analysis at the time of onboarding and periodically. Our Risk Management team will effectively communicate with your organization’s leadership team regarding issues that are monitored and evaluated regularly and will establish a risk assessment plan, PDCA, CAP or RCA, as applicable.
The hazards of not preparing for potential issues can have significant, long-term effects. Neglecting to have comprehensive risk management plans in place can compromise patient care, increase liability risks, and result in financial losses.
Medical and Patient Record Audits
A large risk that healthcare providers identify with pertain to medical/ patient records. Incomplete or inaccurate medical/ patient records can put a healthcare organization at risk. For a multitude of infractions, these risks can lead to allegations of fraud, abuse or malpractice.
Our services include conducting third-party medical and patient record audits that comply with federal, state, local and payer laws, regulations and standards. QPI’s Risk Management Team is established to audit a random sampling of 25% or a complete 100% of a healthcare organization’s medical/ patient records. Adverse and incomplete findings are communicated immediately with your organization for intervention.
Not only will our medical/ patient record audits identify and protect against fraudulent claims or billing activity, they will also serve as a guide to identify opportunities for additional credentialing, contract renegotiations, open care gaps and areas of improvement for patient flow.
Medical Record Audits
Patient Record Audits
- Progress Notes
- Nursing Notes
- Physician Orders
- Consents
- Results
- Consultations
- Medical History
- Medications
- Financial Information
- Opt-in/ Written Consent
- Prescription (DWO) with Chart Notes
- Same/ Similar (Prior to Shipping & Billing)
- Packing Slip and Invoice
- Proof of Delivery
- Assessments and Evaluations
- Certificate/ Letter of Medical Necessity
- ABN (when applicable)
- Payment receipt for copay/ deductible
Certified Risk Manager Responsibilities (at-a-glance)
Payor Requests
- Appeals
- Palmetto GBA—SACU Audits
- Development Requests
- Corrective Action Plans
- Commercial Payor Audits
- Site Visit Reports
Regulatory Training
Access to QPI's Legal Counsel
- Fraud, Waste and Abuse Certification
- Anti-Kickback
- STARK
- Communication Hotlines
- Compliance Reviews and Assessments
- Internal Compliance Audits
- Cybersecurity
- Monitor State/ Federal Regulations
Reporting Tools
- Sentinel Events Assessment
- Fire Drill
- Safety Assessment
- OSHA Assessment
- Hazard Assessment
- Incident Reporting
- Annual Evaluation and Review to BOD
- HIPAA Assessment
Our Risk Management team is dedicated to facilitating assessments and reports virtually on a quarterly basis.
Malpractice and NPDB Reporting
One of the largest risks that healthcare providers face is medical malpractice. Negligent acts or omissions that result in patient injury often prompt legal action.
While we work hard to collectively combat this from happening, we understand that these occurrences take top priority. QPI’s CQRO will work diligently with your organization’s leadership team and legal team to ensure appropriate responses and reporting have been completed and submitted.
Upon identifying any incident, including medical malpractice, QPI’s Risk Management Team will notify the National Practitioners’ Data Bank (NPDB) and assist in submitting applicable reports.
National Practitioner Data Bank Reportable Occurrences
- Medical malpractice payments
- Federal and state licensure and certification actions
- Adverse clinical privileges actions
- Adverse professional society membership actions
- Negative actions or findings by private accreditation organizations and peer review organizations
- Health care-related criminal convictions and civil judgements
- Exclusions from participation in federal or state health care programs (including Medicare and Medicaid)
- Other adjudicated actions or decisions
Credentialing
Credentialing doesn’t stop at licensing. Often, healthcare providers spend time and money applying to become a recognized in-network provider with payers and insurance carriers. Over time, these relationships that we have worked hard to establish are mistaken as “set it and forget it.” Our Credentialing Team ensures that all credentials are maintained, renewed and renegotiated when necessary. QPI will also work with you to personalize a growth strategy to become credentialed with payers and insurance carriers based on your organization’s specialties, service areas and patient needs.
Credentialing for Organizations
Annual Performance Improvement Report
Managing risks can be daunting. While large risks can occupy the majority of our time, often the smaller, recurring risks are forgotten.
QPI’s series of Risk Management tasks collect payer requested performance measures such as Medical/ Patient Record Audits, Billing and Coding Error Logs, Patient Complaints, Adverse Events, and more on a weekly, monthly, quarterly and annual basis.
The Annual Performance Improvement Report provides a systematic process to monitor all service aspects of health care, as delivered to the patient by your organization. It includes an organized framework to identify opportunities to improve quality and patient outcomes.
For transparency, our Risk Management Team will compile all performance measures found throughout HARP, year round, for a years’ end Annual Performance Improvement Report. QPI’s CQRO will contact your organization’s leadership team to review and approve all findings in this report.
