Quality Assurance
  • Screen service providers for the LME network. Providers are screened for clinical competence, the ability to achieve stated outcomes, sound business practices and stability.

  • Provide on site monitoring to validate the appropriate implementation of services outlined for the member. To ensure outcomes are being achieved and the provider is operating within the guidelines of their contract and state rules.

  • Conduct satisfaction assessments to obtain a full picture of how the LME network is meeting member needs. A variety of ongoing systems of satisfaction assessments are utilized.

  • Monitor individual incidents to assess for preventable antecedents, appropriate handling of incidents and the implementation of appropriate follow up. Incident analysis is conducted to identify trends in all areas of review and to ensure quality services are being provided to members.

  • Conduct random billing audits on providers in the LME network. Billing audits are done to ensure that funds are being used for the appropriate level and intensity of services as well as in compliance with federal/state/general accounting rules.

  • Maintain the formal complaint/grievance system within the LME. Ensure members have a voice and due process to formally complain/grieve any decision made which they do not agree with.
  • Provide training/technical assistance to providers in the LME network. Training/technical assistance is offered on best practices as well as systems and skills that will result in Quality Services.

  • Coordinate a system of Continual Quality Improvement. Central to this process is a global CQI Committee that monitors the quality of services provided in the network.

  • Establish minimum qualifications needed for staff provision of particular services to members. Monitor qualifications to ensure appropriate, effective delivery of services identified in each member’s plan. Ensure clinical supervision is being provided to each staff member of the provider based on the staff’s qualifications.

  • Coordinate an ongoing system of review of service delivery and documentation of services provided by the member planning and support services unit within the LME. Systems utilized are case record review, peer review and supervisory record review. Coordinate and monitor activities related to the maintenance of national accreditation for the LME.