QIO/PRO

APS Healthcare’s quality improvement organization (QIO)/peer review organization (PRO) engages in extensive quality improvement processes that include extensive data mining and reporting based on service authorization and paid claims data. APS uses this capability to generate recurring and ad-hoc reports, custom tailored to the customer’s needs.

State Medicaid agencies are federally mandated to contract with a PRO/QIO or QIO-like organization to provide quality assurance and utilization review of healthcare services provided to participants in state Medicaid programs that are reimbursed under a fee-for-service payment system. APS provides:

• Prior and concurrent service authorization
• Post payment retrospective audit
• On-site inspections of care
• Provider in-service education
• Complex care coordination services

APS also assists states in assuring that quality care is provided to medical assistance program beneficiaries.

APS understands that to succeed, a QIO must positively impact the care provided to those beneficiaries with the most challenging needs in the healthcare system. APS has a proven record of success in working to facilitate care for those impacted by high-risk and high-cost health conditions.

APS data analysts conduct complex analyses with data from a variety of sources, including surveys, medical, laboratory and pharmacy claims, vital statistics and other administrative data. Before initiating the analysis, APS staff develops data verification and validation strategies to assess the quality of the data. The end result of this analytic process is an evaluation of the quality of healthcare delivery for state Medicaid programs.

Fundamental to APS’ success in PRO/QIO services is innovative technology. APS CareConnection®, a proprietary Web-based technology platform, collects authorization and quality improvement data via the Internet, and provides that data to authorized care management participants in full compliance with HIPAA requirements. Automating the review of routine, criteria compliant, outpatient authorization requests reduces the administrative burden on providers and improves care management.

APS CareConnection® maintains complete records of treatment history and enables APS to review an individual’s entire course of treatment, rather than an isolated authorization request, to determine the most efficient treatment plan. It also promotes effective care coordination by enabling clinicians to address treatment fragmentation when services are provided by multiple providers.

APS is designated by the Centers for Medicare and Medicaid Services (CMS) as a QIO-like organization.