Quality Assurance Bureau

The Quality Assurance Bureau's primary role is to ensure quality through oversight of all aspects of quality of care, fraud and abuse detection/control, performance measurement, monitoring, and tracking of systemic quality indicators and issues. Primary responsibilities include: Oversight/compliance of quality standards of care as defined by federal and state regulations, managed care contracts and Joint Powers Agreements (JPAs); monitoring multiple comprehensive data reports; reporting trends, utilization, complaints and grievances, critical incidents, performance measures, surveys, and longitudinal studies per managed care organization individually and comparatively; managing the External Quality Review Organization (EQRO) contract for compliance with federal oversight requirements; oversight of the CMS Payment Error Rate Measurement (PERM) Project; conduct payment accuracy measurement studies that produce payment accuracy estimates, strengthen internal controls, quality and accountability; oversight of the CMS Medicaid Integrity Contractors (MIG); conduct audits of Medicaid providers to identify billing errors and decrease the payment of inappropriate Medicaid claims; detection, investigation and prevention of Medicaid fraud; analysis and determination of requests for client disenrollments, exemptions, and PCP lock-in; creating a Salud! Report Card.