Provider Manual

QUALITY MANAGEMENT ACTIVITIES

Total quality management and continuous quality improvement occur within the context of various planned activities. These activities include, but are not limited to, the following:

  1. Risk Management

    The Quality Management / Utilization Management Committee (QM/UMC) monitors:

    1. High Volume Service and Treatment
    2. High Risk Members and Treatment
    3. Intensive Behavioral Health Services (IBHS) for Children and Adolescents
    4. Reportable Events
    5. Quality of Care Activities
  2. Evaluation of the Effectiveness of Services

    The QM/UMC evaluates the effectiveness of services provided to consumers and families. The following domains are included:

    1. Access to Services
    2. Appropriateness of Service Authorizations (Authorization system audits)
    3. Authorization and Grievance Data
    4. Quality of Service Management Planning
    5. Treatment Outcomes
      1. Participation in all data collection and reporting activities required by the Department of Public Welfare
      2. Population-based studies and surveys as approved by the QM/UMC
  3. Evaluation of the Quality and Effectiveness of Internal Processes

    The QM/UMC evaluates the effectiveness of internal processes and overall performance. The following domains and methodologies are included:

    1. Telephone Access Standards and Responsiveness
    2. Responsiveness and Accuracy of Member and Provider Services
    3. Relapse and Recidivism Rates
    4. Overall Utilization Patterns and Trends
    5. Coordination with Other Service Agencies and Schools
    6. Complaint and Grievance Tracking Process
    7. Adequate Capacity in Provider System
  4. Evaluation of the Quality and Performance of the Provider Network

    The QM/UMC uses data to focus on the assessment of health care delivery and patterns and trends in care, rather than on individual occurrences of care. The system includes the following components:

    1. Utilization Patterns
    2. Complaint and Grievance Data
    3. Quality of Individualized Service Plans and Treatment Planning
    4. Reportable Events
    5. Consumer Satisfaction Team (CST) Data
    6. Administrative Compliance
    7. Provider Profiles and Report Cards
    8. Annual Telephonic Satisfaction Survey Data
    9. Clinical Documentation Record Reviews
  5. Monitoring of Significant Member Incidents (Reportable Events)

    Quality Management prepares quarterly reports showing the frequency and type of reportable events by population category (e.g., age, gender, etc.) and by service type. Clinical records may be requested, in some cases, for review by the Carelon Risk Management Analyst. Other avenues are explored as well, in order to complete a thorough investigation. The Medical Director has final authority to close reportable event cases.

  6. Reporting of Suspected/Substantiated Fraud and Abuse

    The Fraud and Abuse Coordinator prepares a written report each quarter, which includes all allegations of fraud and/or abuse, by type of event, sanitized to protect confidentiality, and the outcome of the investigation.

  7. Clinical Records Content, Retention and Storage

    Carelon has established policies and procedures for clinical records content, retention and storage, which encompass physical security, information systems security and staff training. This is monitored in the recredentialing process.

  8. Assessment of Member Satisfaction

    In order to determine if behavioral health services are meeting the needs and expectations of consumers, family members, including parents of children and adolescents, and persons in recovery, the HealthChoices Program has established systems and procedures to routinely assess member and family satisfaction. These systems and procedures include the use of ongoing consumer/family satisfaction team (CFST) providing for face-to-face discussions with consumer and family members as a means for early identification and resolution of problems related to service access, delivery and outcome. Providers are expected to cooperate fully with all CFST activities. An annual statistically valid telephonic survey is also conducted by Carelon. Findings and resulting recommendations from the survey and CFST activities are incorporated into the HealthChoices Program ongoing quality management and improvement program.

  9. Assessment of Provider Satisfaction

    An annual telephonic provider satisfaction survey is conducted by Carelon. Data is reviewed by the QM/UMC and areas for quality improvements are developed and monitored.