Quality Program
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Quality Program

Quality Program

The Quality Program (QP) 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.

Participation in the Quality Program

Participation in our QP activities is required in our agreements with physicians, other health care professionals and facilities. Participation may include:

  • Site visits and record review
  • Adherence to clinical standards
  • Credentialing or re-credentialing
  • Quality of care concerns or complaints
  • Providing evidence of preventive health promotion
  • Providing data for various medical records audits such as the annual Healthcare Effectiveness Data and Information Set (HEDIS®) audit

Providers may be asked to review and provide feedback on proposed or ongoing clinical activities and development of clinical practice guidelines at focus groups or Medical Advisory Committees.

Quality Program scope

The scope of the QP includes developing improvement opportunities and activities throughout our Company that directly impact the experience of our members, physicians, other health care professionals or facilities:

  • Develop focused quality improvement activities (QIAs) including:
    • Clinical QIAs
    • Service QIAs
  • Monitor activities throughout our Company to further the "integration of our processes" including:
    • Access
    • Availability
    • Quality surveys
    • Staff qualifications
    • Advance directives
    • Case Management
    • Member satisfaction
    • Provider satisfaction
    • Inter Rater Reliability
    • Medical record keeping
    • Quality of care concerns
    • Community collaboration
    • Under and over utilization
    • Pharmacy education programs
    • Disease management programs
    • Clinician performance monitoring
    • Coaching and wellness programs
    • Utilization Management: Physical and Behavioral Health
  • Monitor patient safety activities to fulfill our commitment to the safe delivery of care to our members.
  • Support contractual and regulatory compliance.
  • Develop and administer the QP to provide an organizational structure, resources and coordination of quality processes within the Company.

Health Strategies Committee of the Board of Directors

Our Board of Directors has participating providers as directors and on the Health Strategies Committee. This committee meets quarterly to discuss issues surrounding the health care delivery system and provider-related quality improvement activities.

Accessibility and availability standards

Accessibility and Availability Standards

Provider appointment availability

We are committed to providing our members the necessary information to:

  • Be able to use their health plan benefits
  • Have reasonable access to health services
  • Be assured the number of physicians, other health care professionals and facilities will be appropriate to satisfy their health care needs.

Please review this information carefully. If your office currently is not meeting these standards, please take the steps necessary to comply with them to ensure that our members, your patients, have access to quality care. This information and these standards take into account the immediacy of patient needs and common waiting times for comparable services in the community. You should have a system in place in order to evaluate the urgent and emergent needs of members and to determine the appropriate site for care in a timely fashion.

Appointment availability standards

Physicians and other health care professionals will provide or arrange for the provision of covered services to members on a 24 hour a day, seven days a week basis. The following are minimum standards for availability for all lines of business:

Primary care providers

  • Emergent care will be assessed, treated or referred immediately.
  • Urgent, acute care appointments will be scheduled within 24 hours.
  • Preventive care examinations will be scheduled within 42 calendar days.
  • Non-urgent appointments for symptomatic conditions will be scheduled within seven calendar days.
  • Non-urgent, routine appointments for asymptomatic conditions will be scheduled within 30 calendar days.
  • Office wait time for a scheduled appointment will be no more than 30 minutes.

Specialty referral providers

  • Urgent, symptomatic condition appointments will be scheduled within 24 hours.
  • Non-urgent, specialty referral appointments will be scheduled within 30 calendar days.

Behavioral health providers

  • Non-life threatening emergency will be treated within six hours or directed to the nearest emergency room.
  • Urgent care appointments will be scheduled within 48 hours.
  • Routine office visits will be scheduled within 10 business days.

For commercial lines of business

Emergency services
An emergency is defined as the sudden or acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention and that failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy.

Emergent services to screen and stabilize a member are covered if a prudent layperson acting reasonably would have believed that an emergency medical condition existed.

Urgently needed services
Urgent acute care, while not considered life threatening, cannot comfortably be delayed. Practitioners must have a system in place to evaluate the needs of members calling or presenting at the office that enables them to identify conditions requiring urgent and emergent care.

For Medicare Advantage Plans

The provider or the designated covering physician or other health care professional must be available to provide care personally or direct members to the most appropriate treatment setting. If triage is conducted by a health care professional that is not a physician, the minimum credentials of this health care professional must be one of the following:

  • Registered nurse
  • Nurse practitioner
  • Physician assistant
  • Certified nurse midwife
  • Licensed practical nurse

Emergency services
We define emergency services for members enrolled in our Medicare Advantage plans as covered inpatient and outpatient services that are:

  1. Furnished by a physician or other health care professional qualified to provide emergency services, and
  2. Needed to evaluate or stabilize an emergency medical condition.

Emergency medical condition
An emergency medical condition is defined as: A condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, one with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

  • Serious jeopardy to the health of the individual or in the case of a pregnant woman, the health of her unborn child
  • Serious impairment to bodily functions or
  • Serious dysfunction of any bodily organ or part

Urgently needed services
We define urgently needed services for Medicare Advantage plan members as covered services that are provided when an enrollee is temporarily absent from the Plan's service area (or, under unusual and extraordinary circumstances, provided when the enrollee is in the service area but the Plan's provider network is temporarily unavailable or inaccessible) when such services are medically necessary and immediately required:

  1. As a result of an unforeseen illness, injury or condition and
  2. It was unreasonable, given the circumstances, to obtain the services through the Plan

After-hours answering systems

In order for all our members to be able to access their primary care or call share physician after regular office hours, physicians and other health care professionals must have an adequate telephone answering system or service available. If a telephone answering system is utilized after regular office hours, the following guidelines apply:

  • The message must be checked frequently to ensure that it is clear, easily understood and contains accurate information such as telephone numbers.
  • The answering message must include the name and telephone number of the on-call physician or other health care professional (you or the callshare physician) and complete instructions on how to contact the on-call physician or other health care professional.

Messages that only instruct a member to call 9-1-1 or go to a hospital emergency room do not meet the full requirement for 24 hours a day, seven days a week coverage.

If your office utilizes an answering service, please provide the answering service with the name of the on-call physician or other health care professional, and how the member can contact that provider.

Cultural Competency

Legislative requirements emphasize the importance of demonstrating cultural competency in the provision of health services. This includes members who may:

  • Be homeless
  • Have physical or mental disabilities
  • Have a diverse cultural or ethnic background
  • Are limited in English proficiency and/or reading skills

Please review the Cultural Competency tab at the top of this page for more information and resources to support you and your staff.

Non-English speaking and hearing impaired members

  • To ensure accurate interpretation and translation, we strongly encourage utilization of an interpreter service or staff person who is trained in translating medical terminology.
  • Asking family members or friends to act as an interpreter is not appropriate. They may not be familiar with medical terms and translation errors may occur, or information may be overlooked or withheld.

Members with visual impairments

The following information may assist you in providing services to visually impaired patients:

  • Assign a person in your office to assist visually impaired patients. Identify what to do if a patient needs assistance from their vehicle to your office, with form completion, or to and from the restroom or exam room.
  • Braille signs should be posted on restrooms and elevators to meet American Disability Act (ADA) requirements.
  • Guide dogs must be permitted to accompany visually impaired patients to all areas of your facility where patients are allowed. An individual with a guide dog may not be segregated from other patients.

Members with physical disabilities

Medical services are accessible to people with physical disabilities. Participating physicians and other health care professionals must ensure the following provisions for access:

  • Wheelchair accessible offices
  • Clearly-identified handicapped parking spaces

Help in identifying handicapped parking spaces can be obtained from the following sources:

  • Signs: Your state's Disabilities Commission can assist you with obtaining signs designating handicapped (including van-accessible) parking. Signs can also be obtained through other commercial vendors.
  • Striping and stenciling: Parking space painting and stenciling can be arranged through a variety of commercial vendors. See your telephone directory listing under "Pavement Marking" for the name of a contractor near you.

If your office is unable to serve a particular disabled population or individual, please contact our Provider Contact Center so that other arrangements or referrals can be provided.

Access for Medicare Advantage members with special needs

If your Medicare Advantage patient has a serious, complex medical condition and requires additional assistance navigating the health care system, use the Care Management Referral Request form to request case management through our Care Management Intake team. Case management staff will work with your office and the patient to provide assistance with this process, and refer you to the appropriate case manager.

Advance directives

Advance directives

To ensure our members' wishes are met concerning the provision of health care if the member becomes incapacitated and is unable to make those wishes known please comply with the following:

  • If the office has received a signed advance directive, a copy of the document must be prominently displayed in the patient's chart.
  • The office or facility should have copies of advance directives available for their patients to complete, or advise the patient how to obtain one from the hospital or his or her attorney.
  • If your office or facility is currently not meeting these standards, please take the steps necessary to ensure that members have access to quality care by complying with these standards.
Cultural Competency

Cultural Competency

Cultural competency and health literacy
State and federal legislative requirements emphasize the importance of demonstrating cultural competency in the provision of health services. This includes members who may:

  • Be homeless
  • Have physical or mental disabilities
  • Have a diverse cultural or ethnic background
  • Are limited in English proficiency and/or reading skills

We seek providers who speak other languages in addition to English and who have an awareness of the social and cultural composition of the community. Additionally, we require that Medicare Advantage members have access to information in their primary language, and that primary care provider offices have provisions for non-English speaking Medicare Advantage patients.

Please review the resources listed here to develop and improve your cultural competency and health literacy as you or your staff provide care for our members.

National standards and essential references

National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care: The U.S. Department of Health & Human Services (HHS) published the National CLAS Standards to improve the quality of service to all individuals to help reduce health disparities and achieve health equity.

Improving Cultural Competency for Behavioral Health Professionals: HHS also provides a free training to help behavioral health professionals learn how to better respect and respond to patients with unique needs.

Office of Minority Health: The HHS Office of Minority Health includes population profiles, cultural competency information, and an online library, among other resources.

Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations: The American Psychological Association's (APA) Board of Ethnic Minority Affairs (BEMA) established a Task Force on the Delivery of Services to Ethnic Minority Populations in 1988 in response to the increased awareness about psychological needs associated with ethnic and cultural diversity. The task force developed the guidelines to enlighten all areas of service delivery, not simply clinical or counseling endeavors.

Health Literacy: The Centers for Disease Control and Prevention (CDC) offers seven online courses for health professionals covering culture and communication, health literacy and plain language, some of which are free continuing education opportunities.

Health Literacy Universal Precautions Toolkit, 2nd Edition: Consider Culture, Customs, and Beliefs: Tool #10: The Agency for Healthcare Research and Quality (AHRQ) offers this excerpt from their full Health Literacy Universal Precautions Toolkit. Tool #10 focuses on culture, customs and beliefs and how they can influence how patients understand health concepts, take care of their health and make decisions related to their health.

National Council on Interpreting in Health Care: The National Council on Interpreting in Health Care's mission is to promote and enhance language access in health care in the U.S.

For more information

CME/CEU Resources

  • A Physician's Practical Guide to Culturally Competent Care: A Physician's Practical Guide to Culturally Competent Care website offers continuing education and equips health care professionals with awareness, knowledge and skills to better treat the increasingly diverse U.S. population they serve.
  • Quality Interactions: Quality Interactions offers more than 25 clinical and non-clinical eLearning courses for health care professionals; cultural competency resources; and organizational assessment. The eLearning offerings also include behavioral and mental health-focused options.

Non-CME/CEU Resources

  • National Center for Cultural Competence (NCCC) at Georgetown University: The mission of the NCCC is to increase the capacity of health care and behavioral health care programs to design, implement and evaluate culturally and linguistically competent service delivery systems to address growing diversity and persistent disparities, and to promote health and behavioral health equity.

Language access & services

  • Interagency Working Group on Limited English Proficiency (LEP): Created in 2002, the mission of LEP.gov is to share resources and information to help expand and improve language assistance services for individuals with limited English proficiency, in compliance with federal law
  • Interpreter Services: The Washington State Health Care Authority's website dedicated to information on interpreter services information for providers, including information on the sign language request process, program information, resources and program updates.
  • Summary of State Law Requirements Addressing Language Needs in Health Care: Since the early 2000s, the National Health Law Program has charted the development of state laws on language access. This edition of the 50-state survey provides an update on state activities since 2008.

Additional resources

  • Rural Health Information Hub: The Rural Health Information Hub, formerly the Rural Assistance Center, is funded by the Federal Office of Rural Health Policy to be a national clearinghouse on rural health issues. This links to the individual state guides, which provide basic demographics; information on rural health care facilities; and selected social determinants of health for rural areas.
HEDIS reporting

HEDIS measurement and reporting

Healthcare Effectiveness Data and Information Set (HEDIS®) is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) that allows purchasers and consumers to compare quality among health plans.

Regulators also use HEDIS results to evaluate and reward plan performance in various programs such as the Medicare Star Ratings. We are required to report HEDIS values annually on our commercial and Medicare members, making HEDIS a key component of our Quality Program.

Medical and pharmacy claims are the primary administrative data sources for HEDIS and Medicare Star Rating measures. Audit-approved "supplemental" data, such as state immunization registries, laboratory results, vision vendor services and specific electronic medical record (EMR) services, are also used.

NCQA-designated measures rely in part or whole on the addition of medical record data, in combination with administrative data, to achieve valid rates.

NCQA requires a statistically valid sample from all members eligible for these measures. If any of your patients are a part of that sample and their claims do not reflect compliance with the measure, we will need to review their records. We will work with you to complete these necessary reviews.

Provider tips for improving HEDIS scores:

  • Provide clinically appropriate preventive screenings, tests and vaccines at established recommended intervals.
  • Monitor chronic conditions according to established disease-specific guidelines.
  • Accurate and timely submission of claims will reduce the number of medical record reviews required for HEDIS rate calculation.
  • Ensure that medical record documentation accurately reflects services billed.
  • Submit claims for all services delivered. Submit all applicable diagnostic, procedure, and CPT level II codes (whenever possible). If services are not billed or are billed inaccurately, they are not included in the HEDIS scores.

Frequently asked questions about the 2019 chart review:

What HEDIS measures will be included in the 2019 review?

We are reviewing 11 measures this year:

  • Cervical cancer screening (CCS)
  • Colorectal cancer screening (COL)
  • Prenatal and postpartum care (PPC)
  • Childhood immunization status (CIS)
  • Comprehensive diabetic care (CDC)
  • Controlling high blood pressure (CBP)
  • Medication reconciliation post discharge (MRP)
  • Adult body mass index (BMI) assessment (ABA)
  • Weight assessment and counseling for nutrition and physical activity for children/adolescents (WCC)
  • Immunization for adolescents (IMA) - includes human papillomavirus vaccine (HPV)
  • Transitions of care (TRC)

What dates of service are included in the review?

Office medical records are being reviewed for services received in the 2019 calendar year. However, some measures require additional periods of time, especially for exclusions. The specific periods of service for each member will be included with the chart request.

What types of services and information in the medical record will be reviewed?

The types of services reviewed are specific to each HEDIS measure; however, in general, they include:

  • History
  • Lab results
  • Problem list
  • Specialist consultations
  • Chart notes for a specified period

Are we required to participate?

Yes, your provider agreement requires that you participate in quality improvement activities, such as HEDIS. You must provide access to members' records for these purposes at no cost and without requiring a signed release.

What do I need to do?

We have contracted with Change Healthcare to contact providers to schedule record retrieval and perform the record review. Retrieval can be done by secure online upload, on-site (for larger clinics), fax or mail. Instructions for submitting the requested records will be included with the chart request.

Will I be asked to change or resubmit claims?

No.

Will Change Healthcare protect members' personal health information?

Yes, they will follow Health Insurance portability and Accountability Act (HIPAA) guidelines 45 CFR 164.506(c) (4) while collecting and coding member information, in accordance with our signed business associate agreement. We are not reviewing patient history prior to enrollment with us unless contraindications occurred in the past and would impact the HEDIS rate.

What can I do to minimize the impact to our office?

Change Healthcare and our staff will work with your office to identify the most efficient way to obtain the necessary chart information. We recognize that each office is unique and that this review can be time-consuming.

Who do I call if I have additional questions?

If you have questions about scheduling or your specific charts, contact Change Healthcare directly at the phone or fax number included with the request you received. If you have additional questions, please contact Brenda Taylor or Russell Kite:

  • Brenda: Phone (208) 798-2042 or email.
  • Russ: Phone (208) 333-7830 or email.

Additional Resources

  • See our site review standards tab for details about adequacy of medical record keeping.
  • Use our Quality Measures Guide (PDF) for related coding and documentation tips
Provider advisory groups

Provider advisory groups

Our Provider Advisory Council (PAC) and our new Behavioral Health Provider Advisory Council (BH-PAC) both serve as communication and advisory forums for participating providers including primary care, medical specialties and behavioral health. PAC and BH-PAC members practice in communities across our service area and provide input for some of our programs and collaborate with us on initiatives to improve care and services to members.

Provider Advisory Council (PAC)

The primary roles and responsibilities of the PAC include:

  • Providing input and feedback on services provided to members
  • Providing input and feedback on Accountable Health program initiatives
  • Through discussion, participate in quantitative and qualitative analyses of Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) results and other quality measures
  • Providing input and make recommendations to the Quality Programs Committee (QPC) about clinical quality and service improvement activities, including:

    • HEDIS results and improvement strategies
    • Members' access to providers and appointment availability
    • Medication prescribing and adherence measurement results
    • Clinical practice, behavioral health and preventive health guidelines
    • Coordination of care between medical and behavioral health care providers

PAC membership

Membership in the PAC represents a broad spectrum of participating primary and specialty care providers, including behavioral health. Appointments are made based on availability and need by specialty type. To learn more about becoming an active member of the PAC, please contact our Medical Director, Dr. Badolato.

The PAC meets at least semi-annually.

BH-PAC

Primary roles and responsibilities include:

  • Providing input and feedback on services provided to members
  • Providing input and feedback on Regence's behavioral health initiatives
  • Through discussion, participating in quantitative and qualitative analyses of HEDIS and CAHPS results and other quality measures
  • Providing input and making recommendations to the Provider Quality Measurement Oversight Subcommittee of the Quality Programs Committee (QPC) about clinical quality and service improvement activities, including:

    • HEDIS and improvement strategies
    • Behavioral health medical policy review
    • Addressing opioid use disorders and access to care
    • Members' access to providers and appointment availability
    • Operational enhancements to facilitate positive communication
    • Coordination of care between medical and behavioral health care providers

BH-PAC membership

Membership in the BH-PAC represents a broad spectrum of behavioral health providers. Appointments are made based on availability and need by specialty type. To learn more about becoming an active member of the BH-PAC, please contact our Behavioral Health Director, Dr. Jim Polo, or our Behavioral Health Program Director, Dustin Howard.

View helpful information for Behavioral Health Facilities.

Site review standards

Site review standards

In order to provide a sanitary, comfortable experience, participating physicians, other health care professionals, facilities and agree to adhere to the following site standards. Offices will be regularly reviewed to ensure compliance with these standards.

Physical accessibility

  • Exterior is generally accessible; the office is easy to locate, parking is available, clearly identified and handicap accessible
  • Interior is generally accessible; is handicap accessible, rooms are clearly identified and office hours are communicated clearly

Physical appearance and safety

Exterior

  • Building is generally clean and well-maintained
  • Exterior premises are safe

Interior

  • Interior is generally clean and well-maintained
  • Interior premises are safe
  • Fire extinguish system is available
  • There is adequate hazardous product disposal
  • Narcotics are securely locked

Waiting room adequacy

  • There are educational materials available
  • The waiting room is generally clean with adequate seating for the number of providers in the office

Examination room adequacy

  • The patient's privacy is protected
  • There is an exam table in each room
  • There is educational information available
  • There is hand washing available in each room
  • The rooms are generally clean and of adequate size
  • There is an assistant available as needed

Appropriate equipment available

  • There are Sharps containers
  • There is resuscitation equipment or Cardiopulmonary Resuscitation (CPR)-certified staff
  • If in-office X-rays performed, state certification has been obtained
  • If in-office laboratory work performed, Clinical Laboratory Improvement Amendments (CLIA) certification has been obtained
  • There are examination instruments – for primary care physicians this would include:

    • Stethoscope
    • Blood pressure cuff
    • Otoscope
    • Ophthalmoscope

Adequacy of medical record keeping

Physicians, other health care professionals and facilities must establish the following policies and procedures:

  • Confidentiality policy
  • Release of information policy
  • Medical records must be readily available
  • Medical records must be kept from public access
  • The patient charts must be organized and contents secured
  • Procedures for assessing and improving content, legibility, organization and completeness of medical records

In addition, providers must maintain a medical record-keeping system that:

  • Permits encounter claim review
  • Conforms to professional medical standards
  • Permits an internal and external medical audit
  • Facilitates an adequate system for follow-up treatment

All medical records must be maintained for at least ten years after the date of medical services.

Medical records must contain all the necessary documentation to support the services rendered and billed, as well as the medical necessity of those services. Valid Current Procedural Terminology (CPT®) codes, International Classification of Diseases (ICD) codes and Diagnostic and Statistical Manual of Mental Disorders (DSM) codes must be supported by the patient's medical record. If the appropriate documentation is not included, we may be unable to confirm that payment was made appropriately, which can result in requests for refunds from providers.

Providers must include, at a minimum, the following in medical records:

  • Specific and clear treatment plans
  • Information on advance directives
  • Complete, accurate and legible documentation
  • Complete history, examination and medical decisions
  • Identification of all providers participating in the patient's care
  • Diagnostic testing, laboratory tests and radiology reports and results
  • Prescribed medications, including dosages and dates of initial or refill prescriptions
  • Complete descriptions of the patient's concerns and reason for seeking medical care
  • A problem list, including significant illnesses and medical and psychological conditions
  • Evaluation and assessment of the provider's findings and a complete list of all diagnoses
  • Information on allergies and adverse reactions or a notation that the patient has no allergies or history of adverse reactions

Each entry or page in the medical record must include:

  • Progress notes, any improvement in the patient's condition, changes in the treatment plan and updates to the diagnosis
  • Each page must include the patient's name, date of birth and date of service to verify who the patient is and what date services were provided
  • Each entry must have the rendering provider's signature at the completion of the chart note, medical records, operative report or any other medical document in a patient's file. If an entry spans multiple pages, the signature is required at the end of the entry, but the patient identifiers still need to be on each page.