Quality Management

System (QMS)
Intermedix EMS (ALL LOB's)

Quality Centre of Excellence (QCoE)

Global Backend Shared Services (GBSS)
 Contents
1. Quality Management Statement.......................................................... 1
2. Objective............................................................................................... 1
3. Scope..................................................................................................... 1
Quality Management System – EMS (ALL LOB's)
4. Org. Structure....................................................................................... 1
5. Accuracy................................................................................................ 2
Document release date - 05-03-2021 A. Accuracy Calculation
B. Accuracy Target
6. Sampling............................................................................................... 3
Document Version - 1.1 A. Sample Selection
B. Sample Sze
C. Sampling Strategy
Document Classification - Internal 7. Audit Process....................................................................................... 4
A. Audit Steps
B. Audit Checklist
8. Feedback Approach............................................................................. 5
A. Individual Feedback Process
Document Control B. Team / Process Feedback Process
9. Error Correction Process..................................................................... 6
Document Status Active 10. Rebuttal Process.................................................................................. 6
11. Root Cause Analysis............................................................................ 8
Document Classification Internal 12. QA Certification and Calibration......................................................... 8
13. Reporting............................................................................................... 11
Document Approver Quality Head 14. Scoring Methodology........................................................................... 11
15. Product Knowledge Assessment........................................................ 11
Document Prepared by Quality – Lead 16. QA Selection Process........................................................................... 12
17. Roles and responsibilities................................................................... 13
Document Location Policy Tech 18. Work-Flow of Audit Process................................................................ 13
19. QA Suite................................................................................................ 14
Effective Date 05-03-2021 20. Approvals.............................................................................................. 14
21. Targets and Action Items..................................................................... 14
Version 1.1 22. RACI Matrix........................................................................................... 15
23. Source for MIS Team............................................................................ 16
24. Compliance........................................................................................... 16
25. Refreshers and Training....................................................................... 16
26. QA Goal Sheet....................................................................................... 17
27. Transitioning of New Client or Facility............................................... 18
28. Terms and Definitions.......................................................................... 19
29. Change Log........................................................................................... 19
30. Annexure............................................................................................... 20
QMS - IMX EMS

Quality Management Statement Accuracy

To implement Quality Management System as per the R1 way of working and to define the steps A. Accuracy Calculation
and processes with which the Quality team will operate and communicate with all the
stakeholders associated with Quality team. It will be the guiding principle for the functioning of The accuracy on an audited transaction is calculated using the DPU methodology. For IMX EMS
Quality team to carry out all its functions with utmost accuracy and customer satisfaction. business we are utilizing the DPU calculation for which the formula is as per below,
Generating amazing results and growth opportunities in due course.
1 - ((# of Non-Critical/4)+(# of Critical Error))
Formula used
/ Total Audited Accounts
Also, the QMS document will provide the road map for anyone from a New Hire till Executive level
on the functioning and requirements of the Quality team.
The Accuracy calculation takes into consideration the parameters where each transaction is
evaluated on a set of Critical to Quality (CTQ) parameters. In case, if any of the CTQ parameter is
Objective incorrect, the entire transaction will be deemed as defective.
The accuracy for the Phase/Processes will be calculated as an aggregate of all the audits done
To establish Quality methodology for all processes as per the defined Protocols and agreed SLA's. in the calendar month for the respective Processes or SLA groups as per agreement with the
To determine whether AR, Cash Posting and Billing transactions are accurate as per the defined client.
protocols and to provide feedback to the Executives on their errors / defects. Also, to ensure that
consistency is maintained in the end result and to enable the Quality team to identify the areas The Quality Checks are performed in QA suite. QA Suite will be explained in detail in the coming
of improvement among staff members and processes and bring in continual improvement sections.
initiatives for increased efficacy in business and client retention.
B. Accuracy Targets–
Process OJT
Scope
Cash-Posting 95%
To carry out a systematic and independent examination to determine whether quality activities AR 95%
and related results comply with the QMS protocols, and whether these protocols are
Credit Balance 95%
implemented effectively and are able to achieve the set objectives.
Quality Management System applies to all Audits offered by the Quality Team including PR 95%
allocation, production and post-delivery activities. The relevant internal and external issues for
the QMS and actions to address identified as risks and improvement opportunities found are Note: The Quality Audits for the previous month will be closed by the 5th business day of the
considered. following month. There might be chances to extend 2-3 days sometime considering onshore &
technical support dependency for varies reasons
To establish the scope of Quality Management System, we would be considering:
• External and Internal stake holders C. Scoring Methodology
• Requirements of CBO & BSO teams
Calculated based on total transaction/account audited and total defective transactions/account
• Our Quality Methodology
• Critical error - Zero accuracy
• Non-Critical error – 25% impact
Org. Structure
User Opportunity & Accuracy
Resolution Progress Determined with complete claim research? Critical
Sharmil Kurian
VP Appropriate Disposition taken? Critical
Necessary Action Taken in all respective tools Critical
Vishwanath Thakur Singh Clear & Appropriate notes/annotations with all research steps & action taken? Critical
GM
Routed the claim/documents correctly to required department? Critical
Claim moved towards resolution correctly however made non-critical error Non Critical
Raghuvendra Yashwant Murty Shailaja
AM SM AM
HC - 17 HC - 14

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QMS - IMX EMS

Sampling C. Sampling Strategy

As per the sampling strategy below are the 3 critical requirements which are ensured while
A. Sample Selection – in Qualitas tool picking audit samples:
Step 1: Production data for the previous day is captured and uploaded in EMS PMS tool • Each individual Associate must be Audited
Automatically. • Neutral sample distribution (unbiased audit coverage)
Step 2: The Qualitas allocates the accounts to Auditor for Audits as per the defined templates of • Focused audits (as per error trends)
5% and 100% for that particular User.
During production ramp-up, Associate level random sampling is done and based on results
Step 3: The Qualitas tool picks Random sample and allocated the claims to the Auditors. The Quality team gradually moves to focused audits:
samples for Audits are chosen as per Random Sampling method (FIFO Method).
Focused Audits- Any Associate moved to BQ we must perform 100% audits based on the # of
Note:- Auditor can't park or skip any account from his audit worklist (Qualitas) Associates and bandwidth of QA. We must take the maximum claims for that respective
• Sampling Methodology(Monthly)- Associate who is moved to BQ or PIP
* 3 - 5% of production target at site level Category/disposition- based Audits– Based on the Error trend analysis and Pare to analysis, we
need to perform 100% audits on the categories where maximum errors are occurring
• Minimum Sample Size Coverage (Monthly) - We will try to audit 2 sample/associate/per day.
However, it may not be possible owing to multiple reasons & tracking these reasons at BSO to CBO Hand-offs/escalations– When BSO Quality team finds that a particular Associate is
Associate level. The commitment is to complete 3% sample of production target (Site Level) making more errors, then they inform the CBO team that they will be performing more audits for
• New Hires – 5% of production target or 4 audit/per Associate/day for the first 6 months or that Associate.
process moving to steady state, whichever is earlier. We commit these numbers only basis of
QA to Associate ratio being 1:15 for the first six months or process moving to steady state Audit Process
whichever is earlier. Once the process moves to steady state, sampling methodology would
change to 3% of production target at site level. A. Audit Steps
Step 4: The QA works on the assigned accounts and gives his remarks in Qualitas.
The Audit process that is performed is as per the below process flow,
Step 5: MIS team receives automated report from the Qualitas tool for Score card and reporting
purposes.
Data is automatically uploaded Basis on released and
B. Sample Size in Qualitasand random sample Unreleased template random
START based on the respective sample is allocated in Qualitas
templates are generated
Process Steady State Stabilization Stage

EMS-CBR Minimum 20/user/week or @100% as per the Minimum 20% of their production per the
number of users aligned in unreleased template number of users aligned in released template

EMS-PR Released user we are performing minimum There are 17 Queues where user needs get Auditor performs Auditor receives
60/user/month, there are 17 Queues currently certified for each Queue, any user scores 95% NO If Auditor found Audits as per the Accounts for
where user needs to perform production and get in consecutive 2 weeks or more accuracy will an Error Check sheet, SOP Audit in allocation
the certification on each Queue get release from that Queue

EMS-CP Minimum 10 accounts/user/day or (100% as per 3 to 5 accounts/day/user once get released YES
the bandwidth)

EMS-AR 100% sample as per the number of users aligned 20 audit/per associate/month
The Accuracy score Email is triggered to
in unreleased template Auditor moves
is populated as per the Associate for END
to the next
Critical or whom error is marked
account
Non-Critical Error with rework details

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QMS - IMX EMS

B. Audit Checklist Note: If needed, Training team will be involved in the Need based training sessions.

Below is the checklist that the Auditor refers while performing the Audits Step 5: Periodically Process Knowledge Tests (PKT), refreshers; process updates sessions and
FAQ discussions will be imparted to ensure consistency in the performance of the team. (For PKT
https://mcrschicago- refer to section 15)
EMS Audits Checklist .xlsx
my.sharepoint.com/personal/yventapalli_r1rcm_com/Documents/Desktop/QMS
%20Doc/EMS/EMS%20Audit%20Checklist%20-%20Pg%209.xlsx

Error Correction Process (QA Suite Enhancement Area)

Feedback Process and Approach Step 1: Post auditing the Transaction auditor enters the details of the audited transaction in QA
suite for recording the error, score and rework if needed.
The Transaction Quality checks are performed by BSO QA on Qualitas tool. Daily feedback is given
to the Associates for whom Error is identified or marked. A weekly and monthly process wise Step 2:: Email is sent to the concerned associate in standard format with error details and
Error trend analysis report is published along with the accuracy performance of the team. mentioning the correction required (if any) to be done in QA Suite.
A feedback process is initiated post completion of the audits for both individual errors and team Step 3: The associate makes the correction and replies within 24 hours. The associate will attach
errors as per analysis. a screenshot (wherever possible) of the correction made in the reply email.
Feedback timeline – for Error transactions within 24 hours. Step 4: Auditor will crosscheck in the QA Suite tool to ensure that the instructed rework has been
completed by the associate and if the required correction is done.
A. Individual Error feedback process:
Step 5: Auditor updates the correction details in the RCA log attached in the RCA section.
Step 1: BSO Quality auditor identifies and marks a defect. An email is sent to the Respective
associate & respective Ops. Lead mentioning the case, the score, Defect parameter and the Step 6: QA Lead will share the pending correction report with the Ops. Lead.
auditor's feedback.
Error Correction Process Flow (AR & CB)
Step 2: In case of any correction is required, the same will be highlighted in the email for rework.
Note: Rework timeline – within 24 hours from the moment email is received by Ops.associate. A report is
(Please refer to section 9) QA identifies the Error feedback/ generated & sent
START error and mark notification is to Supervisor
Step 3: Supervisor/QA Lead will monitor individual & team performance on a weekly and monthly it in QA Suite sent via QA Suite on all pending
corrections
basis and track the performance in conformation with the SLA's and KRA's.
Step 4: Associate wise error analysis will be performed on all the Ops. Associates. Based on the
Pare to analysis the Bottom Quartile associates(associates with a Quality score which is below
the SLA target). Ops Supervisor and QA Lead will discuss the root cause findings. Feedback will be A report is Supervisor will be
Associate is
generated & sent responsible for
given to the associate in the form of one-one meeting or as required. expected to
END to supervisor ensuring all
correct the error
on all pending corrections are
Step 5: Improvement action plan will be implemented and monitored over the subsequent wherever possible
corrections completed
month's performance to ensure improvement in the associate's performance.

B. Team/Process Error feedback process:

Step 1: Monthly Root cause analysis (RCA) will be performed on the errors identified for the team.
And based on the RCA findings Corrective action plan will be shared with the Ops. Lead. (Please
refer to RCA in section 12)
Step 2: BSO supervisor and Quality Lead will discuss the root cause findings from the RCA with
the associate. Feedback will be given to the Team via Daily Review Meetings.
Step 3: Refresher trainings will be conducted wherever required. In addition, assessments will be
conducted periodically to assess the knowledge level of all the team members. Scores post
each refresher training and assessment will be shared with the Ops. Lead and team. (for
Refreshers / Training refer to section 25)
Step 4: Progress and improvement in overall team performance will be monitored post the
refresher and clarification sessions.
Rebuttal Process
Once the Auditor marks the Error in the QA Suite and an email gets triggered notifying the
associate.
If the Associate disputes that, the Error has been marked incorrectly by the Auditor then the
associate can utilize the Rebuttal process for registering his dispute with the Auditor..
Below is the process of Rebuttal
Step 1: The Associates needs to appeal to the Ops. Lead/Trainer for error reversal, in case of
disagreement with the QA feedback on the error marked.
Step2: Ops Lead will review the error marked along with the QA Lead and revert on it within 48 hrs.

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QMS - IMX EMS

Note: Exception, if both Associate and Ops. Lead are on Leave for more than 48 hours, AM and
above will have Admin access in QA Suite, where they can open and rework on a closed Rebuttal.
Changes will be tracked for such scenario in QA Suite.
Note: If the Rebuttal is not raised within 48 hours, will be deemed to have resolved in QA's favor.
Step 3: The Ops Lead and QA Lead discuss and provide the decision. Their statement will be the
final decision. In case the Team Lead needs clarification on the scenario, (New scenario/ not
covered in SOP, etc.) the same will be referred to the CBO / Client on the same day via an email.
Step 4: Scores will be revised in case of reversal of an error and changes will be made in the
reports and QA Suite.
Step 5: In case of an additional error being marked by Client/CBO in re audit/independent audits,
the Error will be included in the associates score for that claim.
Note: Rebuttal once closed will not be opened again for discussion, under any circumstance.
Associate appeals to the Ops. Lead for Error reversal
Step 1
Ops Lead reviews the Error along with the QA Lead
Step 2
Root Cause Analysis
The Root Cause Analysis (RCA) is very critical for the business. By using Root Cause Analysis (RCA)
the Quality team is able to identify the one baseline problem that is causing the process or the
Associate to miss from achieving the set SLA's or Goals. There are 5 major steps that are carried
out to identify the root cause of any problem. Below are the steps,
Step 1: Gather and Manage Data/Evidence: All RCAs are driven by evidence
Step 2: Identify the Problem
Step 3: Analyze Cause and Effect
Step 4: Prioritize the Top Error Contributors
Step 5: Share the outcome with Operations for Action planning
Note: The responsibility of the Action plan creation and implementation is always with the
Operations Team.
A detailed monthly report will be published internally by the Quality Lead, sharing the error
analysis with the agreed action plans addressing the top errors and error contributors.
Please refer to below template for reporting RCA.

Ops Lead and QA Lead will provide the Final decision. In case if further clarification is needed https://mcrschicago-
then the case will be referred to the Client SME or CBO Team in the Calibration discussion my.sharepoint.com/personal/yventapalli_r1rcm_com/Documents/Desktop/QMS
Step 3 RCA Template - ED.xIsx
%20Doc/EMS/RCA%20Log%20Template%20-%20EMS%20-
%20Pg%2014.xlsx
Scores will be revised in case of a reversal of an Error, and the changes will be made in
QA Suite and score card reports
Step 4

In case there is an additional error marked by CBO/Client in Re or Independent Audit,

QA Certification and Calibration
Step 5 the Error will be included in the associates score calculation
Approach: The Calibration approach defines the process by which the Quality Auditor is able to
effectively evaluate a transaction based on the agreed Critical to Quality parameters (CTQ).
In addition to this, the process defines capturing and preparing a knowledge base that tracks the
Feedback & Rebuttal Process
differences in understanding of a particular situation and the right approach to it as per the SOP
START A document and also as per the Client SME, so that there is always consistency in the cases being
processed / audited on a regular basis.
Error Captured Rebuttal True
Qas

Acknowledgement error Upheld and QA Certification Process -

during discussed over Out come
email received closed the
Transaction the scheduled ?
from agent rebuttal QA will perform Quality Audits for 3 weeks on the prescribed check sheet for the certification.
Monitoring weekly meeting
Quality Lead to send Audits information to CBO team for their review and certification week on
Y week.
Ops Agent

CBO in turn shares the results of their review to Quality management with detailed week wise
Flase error

Error notification agree

received from quality with accuracy scores of BSO Auditor.
team followed by markdown?
verbal feedback QA must achieve >95% of accuracy score each week in order to get certified as Quality auditor.
N If the QA achieves >95% accuracy scores for 3 consecutive weeks, then the QA will be certified to
perform Quality audits automatically for the assigned Users and process.
Ops Supervisor

File a rebuttal Updated scores

Rebuttal Please refer to below table regarding QA certification procedure along with Ramp up plan and
discussed over Expected production count of QA during certification.
against the received from END
the scheduled
markdown quality team
weekly meeting

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QMS - IMX EMS

EMS_QA Certification Ramp Process

BSO Quality Lead for the process will give 3 – 5% Audited
Week Ramp up plan Expected production count transactions to the Client Auditor/SME to audit. The auditors
will complete the audits within 24 Hours and share the audits
Week 1 100% Audit of the QA production with Quality scores 95% 10 External Calibration with the Quality Lead. The Quality lead will calculate the
Variance. In case any variance is observed in rating the CTQ
Week 2 80% Audit of the QA production with Quality scores 95% 20 parameters, the same will be discussed among the auditors to
bridge any understanding gap. MoM will be documented.
Week 3 50% Audit of the QA production with Quality scores 95% 30

If the Variance is > 5%, then QA is given another attempt for 3 weeks
Calibration Flow Chart: -
Note - *In case the QA fails the 2nd attempt, will be referred to the HR for internal movement.
START

QA will complete the Audit training Reviewed account

Audited
sent bank BSO Schedule a
accounts
with Supporting calibration call
sent to CBO
comments END
QA will do perform the Audits as per the process Audit target

BSO
Accounts worked by QA will be audited by CBO team or certified BSO auditor Document the
N Publish
Variance on change over
any account calibration the e-mail
call along with MOM
If QA is abe to maintain the expected variance (<=5%), will get Certified and start auditing as Expert QA
Y
If QA is not able to maintain the expected variance (<=5%), then need to go through
the re-certification process
Agreed samples N

CBO
size reviewed SOP Change
The QA certification will be taken up during the Knowledge Transfer stage or the Ramp up stage, Required?
by CBO
depending upon the agreement with Client for the specific Process Area.
Y
Recertification process: 2 days of additional QA training and will be sent for recertification.
Calibration Process.
Audit the Auditor (Re Reviews)
Calibration calls will be organized to ensure that BSO Auditor and CBOAuditors are calibrated.
• Performed audits will be shared with the CBO team by emailing the audit files.

Gage R and R & Calibration within auditors

• CBO Auditor will do a sample Check on the audits and share the audit files with the BSO Quality
Lead for the process
Methodology: The auditors will be given 3 - 5 transactions
each. All the auditors will audit the transactions • The Quality Lead will investigate the variance and share the report with the RCA of variance with
Internal Calibration simultaneously/independently and the scores will be the CBO Quality Lead
Process more than 1 QA compared. In case any variance is observed in the scores and
rating of the CTQ parameters the same will be discussed • The variance will be discussed in the calibration calls.
among the auditors to bridge any understanding gap. MoM will
be documented and shared internally.
Frequency:
Weekly/Monthly
Gage R and R& Calibration with backup auditor
Methodology: Both, primary and backup auditor/SME will be
given 3 – 5 transactions each. All the auditors will audit the
Internal Calibration transactions simultaneously/independently and the scores will
Process more than 1 QA be compared. In case any variance is observed in the scores
and rating of the CTQ parameters the same will be discussed
among the auditors to bridge any understanding gap. MoM will
be documented and will be shared internally

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QMS - IMX EMS

Reporting
Transaction Monitoring Quality report: Quality Auditor will share Accuracy score on a weekly and
monthly basis. This report will have process wise audit and accuracy details and the overall
accuracy along with the Pareto Analysis of the top error parameters
Re-Assessments & Feedback session would be conducted for the associates who are not
clearing the Assessments.
Correlation study to be performed, to assess the efficacy of PKT and impact on the accuracy
score.

Report Title Content • Once Associate completes Initial process training from Trainer, must attempt the PKT
• PKT is conducted for 50 marks, in which scoring 80% marks is mandatory
Daily Audit
Week 1 Report Details of transaction audited for the day/site
PKT for • PKT should be conducted on topics, including basic Process updates and Basic RCM
• PKT must include more questions on the Critial area's of the process
Weekly
Week 1 Quality Insight Last 3 months and 3 week summer over
• Audit Coverage
New Hire • If Associate is not able to clear the Quality PKT in 2 consecutive attempts, then will be
• Accuracy % with key findings reffered to HR for further action
• QA Calibration Scores
• Bottom Quartiles
• Trainings conducted by QA

Monthly
Week 1 Quality Review Performance summary for the months:
• Pare to display at user & defect • Minimum 1 PKT must be conducted for the Expert users
• BQs PKT for • PKT must contains question on Process updats, Top error trend and General RCM
Expert principles
• The Expert If Associate must score 80% marks to clear the PKT
Report Templates - Associate • PKT must be conducted for minimum of 10 Questions
https://mcrschicago-
my.sharepoint.com/personal/yventapalli_r1rcm_com/Docume
Daily Report. IMX-EMS-CDR.msg
nts/Desktop/QMS%20Doc/EMS/Daily%20report%20IMX-
EMS-CBR%20-%20Pg%2017.msg

Scoring Methodology
Objective is to measure the outcome of audits, report Accuracy of the work done
• Calculated based on total transactions audited and total defective transactions
• Each transaction is considered as 1 unit and if an error is marked in any of the audit parameters,
transaction/unit is considered defective
1 - ((# of Non-Critical/4)+(# of Critical Error))
Formula used
/ Total Audited Accounts
Audit Parameters – Based on the work-type (AR & Credits) audit parameters have been defined
to gauge accuracy of the claim and determine the field where error has been made, below are the
audit parameters for AR along with drill downs in the embedded excel sheet
Product Knowledge Assessment (PKT)
The Product Knowledge Test (PKT) is an assessment given to the associates on a periodic basis,
which has 10-15 questions.
Product Knowledge assessment will be conducted on a monthly basis to check the
understanding of the team on the product, process updates, new learnings and errors from
audits.
The passing score is 80 % and above.
QA Selection Process
A. During a new transition, the Quality Auditor is selected from the IJP based on the performance
of the associate and the interest of the associate in the Auditor role.
B. Steady State – QA IJP is raised to HR as and when there is a requirement/opening which might
be for backfill (due to attrition/movement) or for any new process
C. HR will share the nomination list of candidates with required expertise as per process
requirement
D. All nominations are scanned through the selection procedure
i. Last 3 months' accuracy of the candidates must be above the process threshold (Last
appraisal ranking is considered & min tenuity 12 months is taken.
i. Last 3 months PKT scores must be above the threshold of 90%
iii. No unscheduled absenteeism (NCNS) in the last 6 months
iv. Final interview would be conducted with the Quality manager the candidate(s)
E. Final confirmation mail is sent to Operations stakeholders' based on the selection details.
Note - *Processes where the QA utilization is less than 50 % will have Operations QA. The
associate will be selected from the Operations team with additional responsibility of doing
Quality Audits.

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QMS - IMX EMS

Roles & Responsibilities QA Suite Tool

Roles Responsibilities Qualitas tool is the application that is used by the Quality team for performing the Audits.

Week 1 · Audit claims processed by associates All the requests for Qualitas tool access need to be Approved by Quality Head.
· Feedback sharing on errors identified Only, Quality Leads will have the Admin access in Qualitas tool application.
· Conduct RCA on the errors on a weekly basis and share with the QA Lead
Active participation in Client Calibration sessions & Query sessions –
·
weekly/monthly/need based
Approvals
Quality Auditors · Floor Support All the organizational Approvals for Downtime, Rebuttal and so on will be under the purview of
· Share feedback with associates on client triggered interventions Quality Head. Any request for Approval needs to be send directly to the Quality Head, copying the
· Conduct and manage PKT (Process Knowledge Test) immediate supervisor. Please refer the below table for all details,
· Come up with process improvement ideas
Approval Category Approving Authority

Weekly OT Quality Head

· Prepare and/or validate RCAs for tracking and reporting
· Prepare and/or validate Corrective Actions /Preventive Actions Monthly Manual Audits approval Quality Head
· Participate in client calibration sessions and publish MoM
Rebuttals Approval Quality Head
· Taking ownership of PKTs (Product Knowledge Tests)
· Collate actual performance data at Process and QA level Weekly Downtime Quality Head
Assistant Manager – · Manage KRA for the QA team and share the KRA performance with the
Auditors on a monthly basis Delay in Sending MIS data Quality Head
Quality
· To ensure QAs are completing audits on time and variance with QA Suite Or Qualitas access Approval Quality Head
external/client auditors are much within the acceptable tolerance limit
· Coaching and feedback to the Quality Auditors Process Movement Quality Head
· Working with the Ops. Leads to identify the action plans for Quality Improvement. Quality Head
Additional resource hiring (within Budget)

Additional resource hiring (Over & above Budgeted) PRCM CoE

Workflow of Audit Process Target changes Quality Head
Operations

Ops. Associate Once the claims are

Start
Ops. Associate
receives claims in
Processes the claims completed, Ops. Lead Targets and Action Items
as per the Updates send the data to QA
his/her allocation Lead for Auditing
and SOP Accuracy Targets: QA targets vary based on the RCM function as mentioned below:
A. AR & Credit Balance – 95%.
If the auditor finds The Qualitas sends B. Cash Posting & Billing – 98%. PIP Policy: To deal with performance improvement cases in
The QA Lead uploads The Auditor audits
Quality

any Error, he marks the claim to the Ops. uniform manner across the organization. All employees who are working in frontline roles
data in QA Suite & claims in his/her the error & gives his Associate for rework
allocate claims to allocation as per the comment & score in and also triggers and across functions undergoes below policy.
QA for Audits Update Tracker & SOP QA Suite email
C. Trigger for PIP: If any employee misses the Quality/Productivity targets in ops and related
metrics impacting service delivery in enabling units on repetitive basis.
If the Ops. Associate
The claim is received The Ops. Associate The QA verifies if the does not agree with D. PIP shall be issued by the immediate supervisor including HRBP.
Re Work

by the Ops. Associate makes the claim is corrected the Error marked then
for correciton & correction on the and updates the the Ops. Associate E. Adequate trainings and handholding are done to ensure employee gets a fair opportunity to
ReWork claim & replies to QA comment raises a rebuttal improve his performance with periodic reviews.
request on Qualitas
F. PIP 2 – To be initiated if associate fails to clear the passing threshold for PIP 1.
G. If employee fails to clear PIP 2 would be moved out of the team and forwarded to HR for
The Rebuttal If the Rebuttal is If the Rebuttal is True,
ReButtal

False, the QA Lead the QA Lead updates redeployment or ATL, as necessary.

request is received Stop
by QA Lead who updates comment comment and
and closes the reverses the Error H. Exception to the attached policy is employee being new to the process, as first 2 months are
verifies the claim
Rebuttal and Score learning period.
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QMS - IMX EMS

Qualitas Tool Source for MIS Team

Ops Associate- MIS team picks up data directly from QA Suite report. Manual Audits are sent by QA
RACI Matrix QA Quality - AM Quality - SM Quality Head
Lead on Monthly basis.
Audits R A C I
QA Scores- One view prepared by QA Lead for their Respective scores and sent manually to MIS
Feedback R A C I team (IMCT) on Monthly basis.
Rebuttal R A C I One-view Format for QA's:-
DRM R A C I QA QA QL Data Daily Monthly Audit Total Error Marked
Emp ID LOB Process Target Target Done
Name Name Scource Critical Non Critical
WBR R A C

MBR R A C
Error rate Calibrator PIP LWP QA Guideline
Internal Escalations R A C I Escalation Attendence
target Total Audit Total Error (Yes or no) (Yes or no) (Yes or no) (Yes or no) (Yes or no) (Yes or no)
Client Escalations R A C

Trend Analysis R A C
Value add Continuos Improvement
Reports R A C Remarks
(Yes or no) (Yes or no) (Yes or no) (Yes or no)

Legends: R – Responsible; A – Accountable; C – Consulted; I – Informed

Compliance
The Quality team will follow all the aspects to meet Compliance criteria for Sampling, Audits, OT
and Incentive calculation. Also, Quality team will implement robust steps to prevent any sort of
Incident.
• Compliance can audit based on defined QMS documents to check conformity to this document.

Refresher / Trainings
• Basis on the previous week Top Error category Trend QA will take the refresher training
• Any Associate who moved under BQM category based on their performance QA will provide
individual feedback and the weekly refresher to help them to achieve the expected accuracy.
• For all the BQ movements and PIP initiations the QA and Quality Lead must be kept in loop for
better planning and delivery of Audits.
New policy addressing the involvement of Quality team in Training's will be added here in
future. As per new training plan, QA's will be sharing training needed identification(TNI) on Bi-
Weekly Basis for further execution of training plan by trainers.

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 QA Goal Sheet

Parameter Definition Weightage Measurement Exceptions Source

Timely completion of Auditors to complete the audits 20% Number of days audit target met 2 days a month QA Suite
Audit Target/Day assigned for the day shouldn't be >= 2 days (2 Days
Relaxation)

Variance overall variance to be Overall Calibration Variance:

Calibration Variance considered for all the calibration 1. Internal & External Gage R&R
(Gage R&R) audits including internal, ATA, 20% 2. Audit the auditor
independent audits 3. Variance in independent audits
Overall Variance should be <=5%

QAs to process claims/ QA to process claims or On leave for 3 or more days

Production -2 hours transactions for 2 hours transactions for 2 hours a week. in a week. MIS to track &
a week every week 10% No of transactions should be as report
per the Operations target - Total 8
hours a month

Claims/ transactions processed The transactions processed by If CBO auditor not available,
Production by the QAs to be audited by CBO QA to be audited by the CBO then Ops supervisor to
Quality team - Score to be >= process auditors and the score should be audit these transactions.
10%
target >=95%

A minimum 5 samples per auditor

Internal rebuttals from the Error reversals marked incorrectly

Rebuttals Associates either reversed internally or
(Error Reversals) externally after CBO clarification.
20%
Rebuttal Range wise impact on
auditors - 1-5 - 0%, 5-10 - 25%, 10-
15 - 50%, 15+ - 100%

No unscheduled leaves, no call no Attendance Target - 90% Monthly attendance

Attendance 10%
show & monthly attendance

Timely Refersher Session, Mail Timely Conducting BQM, Weekly Timely Adherence/
Acknowledgement/Response, Refresher Session, DRM, Floor Proactive Response
Basic Deliverables 10%
DRM, Floor Support, Etc. Support - Handling Queries,
Monthly PKT Etc.

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QMS - IMX EMS

For process movements, new QA promotions and QA moving to existing business. Initial month
would be considered as Training Month for process learning/certification program. Terms and Definitions
st • QMS – Quality Management System • BQ – Bottom Quartile
1 audit month 75% of audits/day target (remaining metrics has to be met) and 2nd month
onwards – 100% audits/day as usual. • QA – Quality Analyst or Auditor • AR – Accounts Receivable
• RCA – Root Cause Analysis • CP – Cash Posting
Transitioning of New Client or Facility • Ops Lead – Operations Leader • DE – Demo Entry
• QA Lead – Quality Leader • DP – Denial Posting
• Transition team to share the details (headcount, volume, site information etc.) at least couple of
months before the transition • PIP – Performance Improvement Plan • CBR – Credit Balance
• Transition team to also ensure that the host accesses for the QAs are raised well in advance • ATL – Asked to Leave • CBO – Central Business Office (On-Shore office)
along with the list of Associates • Quality AM – Quality Assistant Manager • BSO – Base Services Office (Off-Shore office)
• Commitment on audit %age during transition should be given in consultation with the QA • Quality SM – Quality Senior Manager • Gage R&R – Gage Repeatability and Reproducibility
Lead/QA Manager/QA Sr. Manager
• HRBP – Human Resource Business Partner • CTQ – Critical to Quality
• Transition team to also work with training team to align a trainer from day 1 of transition
• MoM – Minutes of Meeting • SLA – Service Level Agreement
• It should be Trainer's responsibility to own the SOP creation. QAs &Ops. Supervisors shall provide
inputs • KRA – Key Result Area • SME – Subject Matter Expert

• MoM for SOP calls to be prepared and owned by Trainers • PKT – Process Knowledge Test • HIM – Health Information Management

• QA team to publish the scores along with the detailed RCA on a weekly basis across business • NCNS – No Call No Show
• IJP – Internal Job Posting
QA-Transition framework: - • RCM – Revenue Cycle Management
• HR – Human Resource
QA - Transition Framework - New Account/Site Transition
• DPU – Defects per Unit
• DPO – Defects per Opportunity
• SOP – Standard Operating Procedure
• Ops - Operations

Transition Steady State

Definition 0-6 months 7th month onwards

(subject to performance)
Change Log
QA Ratio 1:15 1:25 Any changes/additions to the Quality process will be updated on this QMS document and the
change log.
Sample %age @ an account level 5% 3%
The QMS will be shared for internal approval whenever there are changes to the internal
Audits/Associate (Refer to Section 6 A) 4 audits/Associate/day 2 audits/Associate/day processes
QA Lead Ratio 1:12 1:12 In case of any changes to the external processes (Sampling, Accuracy, QA methodology, Check
Responsibility Matrix the checker approach) client approval on the updated QMS will be required.
Host Access Responsibility Transition Team QA Lead to share the details with
Transition Manager Version Page No Changes By Change Date RACI Matrix
Number
SOP Creation Training & Quality Training & Quality to work together
with Site Teams Version
1.2
QA Identification Quality Lead/QA Sr. Manager

QA Certification Quality Lead/QA Sr. Manager

JAR Session Ops, Quality & Training

RCA QA Lead

18 19
QMS - IMX EMS

Annexure Category Types of Errors Root cause QA recommendations

Details to be Linked to destination pages as per the below details,

Page – 19

Critical errors Scores-8

Correct Insurance Template 1

Correct Policy ID 1

Appropriate Adjustments Applied 1

Billed Primary/Secondary/Tertiary Insurance Appropriately 1

Correct claim/denial/reject reason Identified 1

Account Follow up (2 days) 1

Account worked correctly 1

Provided Notes within the comment Section 1

Non critical errors

Demographic information Score 6

Patient has Correct Demographics 6

Error Type

1. Bad address indicated, but did not update address

2. Correct dob notapplied to the account

3. correct patient name not applied to the account

Last 5 Days Accuracy
4. SSN found,but was not added to the account
Audit Date 10-Mar-2021 11-Mar-2021 12-Mar-2021 13-Mar-2021 15-Mar-2021
Insurance Information Score 36
Accuracy 95.92% 94.48% 92.66% 96.67% 98.09%
Correct Insurance Template (Not Currently Billed) 10

Adding/ Removing Insurances 8

Last 3 Weeks Trend
Provided External Verififcation Resources 8
Week 26 Week 5 Week 12
Jan'2021 Feb'2021
Correct Policy ID (Not Currently Billed) 10 Team Feb 2021 Mar 2021 Mar 2021
Accuracy
98.21% 95.98% 95.94% 95.47% 97.78%

Top 3 Contributor date Overall Top 3 Errors

User Name Error% Error type Error %

Madhuri, S 93% Misleading, incorrect, not full notes 6%

Anjum, Sana 91% Unnecessary txn added 4%

Ali, Sohail 47% Payments/ adj have deposit dates, 4%

supporting docs, links

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