QualChoice Performing Post-Payment DRG Clinical Validation Audits of Facility Claims

At QualChoice, we work to provide operational and quality excellence at every level of our business. To ensure high quality claims processing and payment accuracy, we began conducting audits of our facility claims in February of this year. We have partnered with CERIS, a healthcare claims review service, to ensure that the DRGs billed correlate to the diagnostic, procedural, and discharge status coded in the patient’s medical record on a post-payment basis. 

Claims should be billed and coded according to QualChoice’s policies and industry-standard coding guidelines for the bill type. This includes the Uniform Billing Editor, AMA, CPT^®, CPT^® Assistant, HCPCS, DRG guidelines, the CMS National Correct Coding Initiative (NCCI) Policy Manual, NCCI table edits, and other applicable CMS guidelines.

QualChoice or CERIS may contact you to request documentation, such as medical records, to conduct the post-payment audit. Once you have been contacted, please make sure to submit the requested information within seven calendar days.



If you have any questions about the post-payment DRG audit, please contact our provider relations team at 1-800-235-7111 ext. 7004. You can also email any inquiries to PR@QualChoice.com.

Updated Forms Available on the Find a Form or Document Section of QualChoice.com

Last year we made important updates to many of our forms, including revised fax numbers. To make sure you always have the most updated information, please visit our Find a Form or Document page each time you need to submit a form.

Health Literacy and Patient Outcomes

Personal health literacy is the degree to which individuals can find, understand, and use information and services to inform health-related decisions and actions for themselves and others. Higher health literacy often leads to better patient outcomes.

Why is health literacy important?

• Health literacy is a key social determinant of health (SDOH), which can contribute to health disparities among groups of people:
• Populations with higher health literacy are found to be healthier than those with lower levels, presenting a challenge to achieving health equity.
• According to the National Assessment of Adult Literacy (NAAL), people are more likely to have below basic health literacy skills if they:
• Self-reported poor health
• Were age 65 or older
• Lived below the poverty level
• Were Hispanic or Black

 What are some health literacy statistics?

• According to the Centers for Disease Control and Prevention (CDC), nearly nine out of ten adults struggle to understand and use personal and public health information if it contains unfamiliar or complex terms.
• The CDC states limited health literacy costs the healthcare system money and results in higher than necessary morbidity and mortality. In fact, improving health literacy could prevent nearly one million hospital visits and save over $25 billion a year.
• According to the NAAL, health literacy is divided into four levels:
• Below basic — only the most simple and concrete literacy skills
• Basic — skills needed to perform simple, everyday literacy activities
• Intermediate — skills needed to perform moderately challenging activities
• Proficient — skills needed for more complex and challenging literacy activities (such as navigating the healthcare system)
• Some findings from the NAAL include:
• 36% had below basic or basic health literacy skills.
• 53% had intermediate health literacy skills.
• Only 12% had proficient health literacy skills.
• Women’s average health literacy score was six points higher than men’s average.

 How can providers improve health literacy?

• Encourage patients to ask questions. Take time to explain how treatment options might affect their condition and wellbeing.
• Develop and distribute health information that is accurate, accessible, and actionable.
• Provide information at an appropriate grade level.
• Use graphics and pictures instead of long written instructions.
• Support and expand community efforts to provide healthcare education that is culturally and linguistically appropriate.

Appointment Accessibility Standards

At QualChoice, we’re committed to making sure our members have timely access to care. We follow accessibility requirements established by regulatory and accrediting agencies and monitor compliance with these standards at least once per year. We review the results to ensure adequate appointment availability and access to care and to reduce inappropriate emergency room utilization. Timely access to care can help members detect and manage chronic conditions as well as help them address more emergent health needs. The chart below reflects our appointment availability guidelines. 

27th Edition of Care Guidelines Now Available from MCG Health: Changes Effective June 1, 2023, for QualChoice Providers

MCG Health released the 27th edition of the MCG care guidelines. This year’s updates include new guidance to support evolving levels of care and health equity, as well as analytical insights on hospital admit rates and length of stay data for acute viral illness (including COVID-19).

View the MCG Health 27th Edition of Care Guidelines

Effective June 1, 2023, QualChoice will follow this new version of the clinical criteria guidelines.