Cost and quality
Quality Program

Quality Program

The Quality Program supports our commitment to ongoing quality care for our members. We have developed standards and performance goals and continue to monitor them to identify improvement opportunities.

The Quality Program includes:

  • Accessibility and availability standards
  • Advance directives
  • HEDIS reporting
  • Provider advisory groups
  • Site review standards
Member tools

Member tools

Patient reviews

We believe in the power of information to transform the health care system. The Patient Reviews feature on our website gives our members the opportunity to provide feedback on their experiences with providers, including physicians, dentists, other health care professionals and facilities.

Members have two access points to provide feedback:

From a processed claim, accessed within a member's account

From the provider profile within the authenticated Find a doctor tool

Our members can give providers an overall or detailed rating and provide comments about their experience. The reviews are posted to the Find a doctor tool and are visible to all public and authenticated users.
Patient Reviews allow members to share their input, creating a level of patient transparency and directness. We have taken these steps to encourage responsible use of this feature:

  1. Members must use a unique screen name and agree to our transparency vendor’s conditions of use (PDF) (beginning on page two) before posting any comments about their experience with a provider.
  2. The conditions of use prohibits members from posting any material or information that is "illegal, unlawful, obscene, threatening, harassing, abusive, harmful, false, misleading, defamatory, or invasive of privacy." Members are also required to acknowledge that they are legally responsible for the information they post on the tool.
  3. We review each comment before it is posted to determine whether the comment violates the conditions of use.

If you feel that your patient's comments violate the conditions of use, please send your appeal in writing to your provider experience manager. You will be notified within three business days that we have received your appeal. The Patient Reviews appeals team will then notify you of their decision within 10 business days. If the patient's comments are determined to adhere to the conditions of use, the comments will remain posted. However, if the appeals team determines that the patient's comments violate the conditions of use, the comment will be removed.

Join the conversation

If you would like to post a response to your patients' comments, begin by:

Carefully reviewing our transparency vendor’s conditions of use (PDF) (beginning on page two)
Completing the Provider response form (PDF) (on page one)
Submitting it to

Before your comments are posted:

  • They will be reviewed by the site moderator.
  • If accepted, your comments will be posted within two business days and will be visible to all users within the Patient Reviews section of the provider profile.

    • You will be notified if your comments violate the conditions of use and, therefore, will not be posted.

Cost estimator

Our members can access estimates for certain medical procedures and services using the Cost Estimator. The tool is integrated into our Find a doctor tool, helping members understand their treatment options so they can make more informed health care decisions in partnership with their providers.

The Cost estimator gives our members provider- and location-specific costs at the:

  • Service level (a single procedure)
  • Treatment level (diagnosis through episode completion)
  • Encounter level (services from check-in through check-out for a visit or stay)

Members can search by more than 1,600 common treatments, procedures and services, including:

  • Surgeries
  • Office visits
  • Diagnostic labs
  • Physical therapy
  • Well-baby check-ups
  • Immunizations and vaccines
  • Pregnancy services (delivery)
  • Imaging services, including MRIs, X-rays, etc.
  • And more

The tool allows members to compare options based on the estimated average cost and treatment timeline. Members search for cost estimates within their selected geographic area. Cost results are based on average estimates from a 12-24-month period and are tied to the member's specific benefit plan. The Cost estimator includes provider quality information and reviews to help our members select a provider that is right for them.

The cost estimate incorporates the member's:

  • Preventive care benefits
  • Out-of-pocket maximums
  • Accumulators (the amount of deductible met by processed claims)
  • Covered benefits, including preventive care benefits availalbe at no cost to the member
  • Cost share information (including coinsurance, visit limitations, upfront benefits and/or copayments)

Cost Estimator results are based on the average cost of a medical service or procedure (minimum three claims submitted by a Preferred provider with six months of data for professionals and 12 months for facilities). The data are analyzed to exclude outliers. Therefore, your facility, practice or some of the services you offer may not be included in the results if the thresholds are not met. Members can review their benefit information within their authenticated account or by contacting Customer Service.

Availity’s Patient Cost Estimator Tool

Use the Patient Cost Estimator tool on the Availity Portal to create an estimate of your patient’s payment responsibility specific to their treatment or service. The estimate is based on a real-time benefit snapshot. This allows you to know and share patient responsibility information before or at the time of service and collect the member’s cost share before the appointment is over.

Find out how much your patient will owe in real-time

After you submit an eligibility and benefits inquiry on the Availity Portal, you have the option to create a patient cost estimate using the Patient Cost Estimator tool. The tool uses a combination of real-time member eligibility, benefits and provider network pricing to create the estimate for a treatment or service for a specific member as of the current date.

Watch a demo and learn more

Availity’s online resources will help you get the most out of their Patient Cost Estimator tool. Their training helps make cost estimating simpler and more efficient. Login to the Availity Portal to watch a demo to learn more about using the tool: Help & Training>Get Trained> Catalog>Patient Cost Estimator - Training Demo.

Note: This tool does not provide estimates for the following:

  • Facilities for inpatient hospital care
  • Dental services (coming later this year)
  • A member who is not eligible at the time of the request

Use of the tool for estimating costs is not a guarantee of benefits, eligibility or payment because member information may change before claims are received.

Community collaboratives

Community collaboratives

We make quality measures available on a community basis by partnering with community collaboratives. Community collaboratives are organizations that bring data from broad sources together to create quality performance measures that can be used by all in the community.

By providing useful quality and cost information to our members, we are creating a culture where patients learn to access and experience value in health care.

We decided to pursue this strategy for many different reasons, including:

  • Learning is shared
  • Duplication is minimized
  • The combined results are greater
  • Access to national support/external resources may be more readily available

We actively support and participate in the following community efforts:

The Washington Health Alliance

The Washington Health Alliance is made up of community members (employers, physicians, hospitals, consumers and health plans) working toward a shared goal of improving the quality and costs of health care in their area. While the organization is focused on the Puget Sound area—King, Kitsap, Pierce, Snohomish and Thurston counties in Washington—this collaborative group is viewed as a regional model.

Community Checkup Report

Medical and technical experts throughout the region worked together with the Alliance to develop the Community Checkup Report, providing a foundation for improving health care quality and affordability. Compare health care at clinics or hospitals, and activities of health plans statewide.

Washington State Hospital Association

Today, there are 98 community hospitals in Washington State. The Washington State Hospital Association takes a major leadership role in issues that affect delivery, quality, accessibility, affordability and continuity of health care.

The Washington State Hospital Association and its member hospitals publish information which is available to consumers. This information allows consumers to make informed decisions about where they choose to seek care.

In addition, WSHA assists policy makers and the public measure the cost and quality of hospital care. Information on hospital pricing and quality and answers to commonly asked questions about hospital bills can be found on the WSHA Web site under Hospital Transparency.