An integral component of the Premier Blue Quality Improvement Plan is the evaluation of the health care rendered to members by contracting providers through medical record review.
The initial step in improving health care through retrospective review is to identify areas for improvement. Medical record documentation merits special consideration in evaluation the appropriateness and effectiveness of the health care members receive. Pertinent information collected from the medical record is analyzed according to established criteria and implicit medical knowledge by quality improvement staff.
Review staff and peer reviewers perform a thorough and comprehensive review of the member's medical records. Providers involved in the care under review are encouraged to take an active role in the review process, providing additional information and clarification when appropriate.
Quality improvement staff works cooperatively with peer reviewers and providers in the development of solutions to identified problems and the evaluation enhancements of efforts to improve health care processes.
Requests for medical information
In order to ensure the integrity of each medical review, reviewers must have complete and accurate medical records at their disposal. Provisions in both the provider and member contracts make it possible for Premier Blue to obtain copies of member medical records from providers, at no charge and without additional signed consent from the member.
New questions relating to member consent for quality improvement activities have recently arisen due to the Health Information Portability and Accountability Act (HIPAA) Premier Blue adheres to the Kansas Medical Society's position that under HIPAA, a special consent from the member to provide copies of their medical records to Premier Blue is NOT necessary, as quality improvement review activities are covered under the privacy provisions of treatment, payment and health care operations.