Medical Audit Sample Clauses
Medical Audit. The Division shall conduct, at minimum, annual medical audits of the Contractor during which the Division will identify and collect management data including information on the use of services and enrollment and disenrollment policies to ensure that the Contractor furnishes quality and accessible health care to enrolled beneficiaries. The Division will review any of the Contractor's policies and procedures for compliance with the terms of this Contract and any policies and procedures for Plan Services. The Division shall also procure an annual external review with follow-up review of the quality, appropriateness and timeliness of health care services, provided by or on behalf of the Contractor, by an independent peer review organization under contract with the Division or a private accreditation body and the Contractor shall cooperate with the party conducting this review. This evaluation shall be based upon the documentation present in medical records, personal interviews, aggregate data, complaints, grievances or other data received from Enrollees or providers. The Division will investigate any suspected cases of fraud and abuse in the delivery of services.
Medical Audit. The Insurance Company shall carry out regular inspection of hospitals, periodic medical audits, to ensure proper care and counseling for the patient at network hospitals by coordinating with hospital authorities.
Medical Audit. Tucson Surgery Center conducts a program of medical audit and the patient’s medical information may be reviewed and released by employees, members of the medical staff or other authorized persons to appropriate agencies as part of this program.
Medical Audit. Scope
a. The scope of medical audit under the Scheme shall focus on ensuring comprehensiveness of medical records and shall include but not be limited to:
(i) Completeness of the medical records file.
(ii) Evidence of patient history and current illness.
(iii) Operation report (if surgery is done).
(iv) Patient progress notes from admission to discharge.
(v) Pathology and radiology reports.
b. If at any point in time the SHA issues Standard Treatment Guidelines for all or some of the medical/ surgical procedures, assessing compliance to Standard Treatment Guidelines shall be within the scope of the medical audit.
c. The Implementation Support Agency shall conduct the medical audit through on-site visits to the concerned EHCPs for inspection of records, discussions with the nursing and medical staff.
d. The indicative process of conducting medical audits is set out below and based on this the ISA shall submit its detailed audit methodology to the SHA for approval:
(i) The auditor shall check the data before meeting the EHCP authorities.
(ii) The audit should preferably be conducted in the presence of the EHCP’s physician/ treating doctor.
e. The medical audit will include a review of medical records in the format (Indicative) specified in Schedule 2.7.
Medical Audit. In case of any claim, a doctor designated by the INSTITUTE may examine the Insured whenever necessary. Furthermore, the Insured expressly authorizes any officers the INSTITUTE may designate to consult and compile all the information contained in his/her files in any hospital center, clinic or doctor’s office, whether in Costa Rica or any other part of the world. CLAUSE XI