Quality Improvement Program Description

Transcription

1 2015 Quality Improvement Program Description Approved by the Board of Directors: March 19, 2002; April 22, 2003; April 20, 2004; April 26, 2005, April 25, 2006, February 27, 2007, March 25, 2008, March 24, 2009, March 23, 2010, April 26, 2011, April 24, 2012, April 23, 2013, April 24, 2014, April 2015

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3 2015 Revisions Page Addition/Revision Rationale Throughout the To reflect current staffing and title changes Staff titles and committee composition document 17 No longer functioning committee, activities Deleted Benefit Interpretation Committee incorporated into the Ops Committee Updated to reflect activities for current product Behavior Health Services lines. 26 Refined Cultural and Linguistic objectives To clearly define purpose of the objectives 27 Added High Risk to title with Complex Case Management. Listed types of members with complex health issues being addressed by the Complex Care To indicate the complex case management is high risk case management. To define complex health issues being addressed (High Risk) Management Program 50 Specific components to be included in the Annual To document NCQA critical factors Work Plan Throughout the Changed Physician Reviewer to Medical Medical Director is responsible for clinical document Throughout the document Throughout the document 66 Director Added who holds an unrestricted license to practice medicine in the state of California to description of Chief Medical Officer and to Medical Director. Changed Director of Health Care Operations to Director of Pharmacy Services Added definition of medical necessity 73 Added Community Health Group s Chief Medical Officer, who holds an unrestricted license to practice medicine in the state of California, is responsible for Delegation Oversight. Updated P & T Committee membership 74 composition review To comply with state regulations Title change To comply with DHCS and CMS requirements for the coordinated care initiative. To comply with state regulations To reflect current Committee membership 78 Eliminated reference to Healthy Families Program To reflect current processes and practices 78 Added clarification regarding Medicare formulary review process To reflect current processes and practices 81 Added statement regarding communication of future Medicare formulary changes To reflect current processes and practices 85 Added statement that provider standing with both Medicare and Medicaid is monitored To reflect current processes and practices

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5 Table of Contents Mission Statement... 1 Authority and Responsibility... 3 Purpose... 3 Goals... 3 Functions... 4 Objectives... 4 Scope of Quality Improvement Program... 6 Annual Review and Update of Quality Improvement Program... 6 Organizational Structure... 7 Role of the Chief Medical Officer... 7 Designated Behavioral Health Practitioner... 8 Lines of Communication and Informational Flow... 8 QIP Committees Members... 8 QIP Committees Meetings... 9 Quorum... 9 QIP Committees Minutes Committee Agenda Corporate Quality Improvement Committee (CorpQIC) Clinical Quality Improvement Committee Credentialing Sub-Committee Pharmacy and Therapeutics (P&T) Committee Utilization Management Committee (UMC) Technology Assessment Sub-Committee Service Quality Improvement Committee Member Appeal Committee Corporate Compliance Committee Public Policy Committee (Member Advisory Committee) Delegated Oversight Committee Behavioral Health Advisory Committee Other Meetings Corporate Quality Department Credentialing Department Role of Participating Practitioners Conflict of Interest Confidentiality Behavioral Health Services Member Safety Quality Issue Identification Cultural and Linguistic Objectives Complex Case (High Risk) Management Data Sources and Staff Resources Health Information System Quality Improvement Program Activities Prioritization Use of Committee Findings Clinical Practice Guidelines Preventive Health/HEDIS Disease Management Continuity and Coordination of Care Risk Management Member Complaint and Grievance/Appeals Monitoring Practitioner Compliance Monitoring i

6 Table of Contents continued Practitioner Credentialing Process Practitioner Peer Review Process Member Health Education Delegation Annual Quality Improvement Work Plan Approval of the Quality Improvement Program Utilization Management Program Description Philosophy Purpose Scope Goals Objectives Functions Accountability and Organizational Structure Utilization Management Committee Technology Assessment Sub-Committee Utilization Management Staffing, Qualifications, Training Confidentiality Integration and Linkage with Other Activities Communication Services Medical Review Criteria Review of Requests for Health Care Services Denial Process Appeals Delegated Utilization Management Utilization Management Program Evaluation and Process Monitoring Pharmacy and Therapeutics Committee Scope Structure Member Selection Criteria Term of Service Meetings Record Keeping and Reporting Major Responsibilities Conflict of Interest Confidentiality Committee Functions Formulary Review Process and Criteria Development of Review Material for Formulary Consideration Selection Criteria for Formulary Drug Status Distribution of Formulary and Communication of Pharmaceutical Management Procedures Medical Exception Request Review Criteria and Process Pharmacy Patient Safety Over- and Under-Utilization Monitoring and Prevention Delegation Oversight Appendixes A Quality Improvement Program Committees Structure Organizational Chart B Quality Improvement Program Information Flow Chart C Confidentiality and Conflict of Interest Statements D Continuous Quality Monitoring Cycle E Delegated Services Agreement Template & Delegation Grid F Organizational Charts G Policies ii

7 Quality Improvement Program Description Mission Statement Community Health Group is dedicated to maintaining and improving the health of our members by providing access to quality care and offering exceptional service to diverse populations. 1 QIP 2015

8 QIP Quality Improvement Program Description

9 Authority and Responsibility Community Health Group s Board of Directors (Board) assumes ultimate responsibility for the Quality Improvement Program (QIP) and has established the Quality of Care Committee to oversee this function. The Board passed a resolution defining the QIP as an organization-wide commitment. This resolution ensures the Board a central role in monitoring the quality of health care services provided to members and striving for quality improvement in health care delivery. The Board authorizes and designates the Chief Executive Officer (CEO) as the individual responsible for the implementation of the QIP. The CEO has delegated oversight of the day-to-day operations of the QIP to the Chief Medical Officer. The Corporate Quality Improvement Committee (CorpQIC), and the Chief Medical Officer have the responsibility of planning, designing, implementing, evaluating, and coordinating the patient care and clinical quality improvement activities. The CorpQIC reports the QIP activities to the Board of Directors. The Board of Directors has delegated this authority to its Quality of Care Committee. Performance accountability of the Board of Directors includes: Annual review and approval of the Quality Improvement Program Description, Quality Improvement (QI) Work Plan and Quality Improvement Program Evaluation. Review status of the QIP quarterly. Evaluate effectiveness of QI activities and provide feedback to the CorpQIC as appropriate. Establish direction and strategy for the QIP. Purpose The Quality Improvement Program provides a formal process to objectively and systematically monitor and evaluate the quality, appropriateness, efficiency, safety, and effectiveness of care and service utilizing a multidimensional approach. This approach enables Community Health Group to focus on opportunities for improving operational processes as well as health outcomes and satisfaction of members and practitioners/providers. The QIP promotes the accountability of all employees and affiliated health personnel for the quality of care and services provided to our members. The goals of the QIP are to: Goals Provide timely access to high-quality healthcare for all members, through a cost-effective, safe health care delivery system that objectively and systematically monitors and evaluates the quality and appropriateness of health care and services; Pursue opportunities to improve health care, services and safety; and Resolve identified problems in a timely manner. 3 QIP 2015

10 Community Health Group will achieve these goals through the implementation of well-established health management techniques that allow continuous monitoring of the entire health care process plus clinical outcome evaluations. Through these goals, Community Health Group will continually improve health care delivery and achieve the best outcomes of care possible. Functions The Quality Improvement Program functions include, but are not limited to: Implement a multidimensional and multi-disciplinary QIP that effectively and systematically monitors and evaluates the quality and safety of clinical care and quality of service rendered to members. Improve health care delivery by monitoring and implementing corrective action, as necessary, for access and availability of provider services to members. Improve health outcomes for all members by incorporating health promotion programs and preventive medicine services into all the primary care delivery sites. Evaluate the standards of clinical care and promote the most effective use of medical resources while maintaining acceptable and high standards. This includes an annual evaluation of the Quality Improvement Program. Ensure effectiveness of continuous quality improvement activities across the organization. Conduct effective oversight of delegated providers. Objectives Design and maintain the quality improvement structure and processes that support continuous quality improvement, including measurement, trending, analysis, intervention, and remeasurement. Comply and coordinate with all governmental agency requirements. Support practitioners with participation in quality improvement initiatives of Community Health Group and all governing regulatory agencies. Establish clinical and service indicators that reflect demographic and epidemiological characteristics of the membership, including benchmarks and performance goals for continuous and/or periodic monitoring and evaluation. Maintain an ongoing up-to-date credentialing and recredentialing system that complies with Community Health Group s standards, including primary verification, the use of quality improvement, and other performance indicators in the recredentialing process. Measure availability and accessibility to clinical care and service. Measure member satisfaction, identify and address areas of dissatisfaction in a timely manner through: quarterly analysis of trended member complaint data; member satisfaction surveys; and solicitation of member suggestions to improve clinical care and service. Monitor, at least annually, member and practitioner satisfaction with the Utilization Management Program. Continue to develop, adopt, and adapt practice guidelines (including preventive health) reflective of the membership. Measure compliance with a minimum of two guidelines annually. QIP

11 Measure the conformance of contracted practitioners medical records against Community Health Group s medical record standards at least once every two years. Take steps to improve performance and re-measure to determine organization-wide and practitioner specific performance. Develop studies or quality activities for member populations using demographic data. Studies and/or activities are designed to identify barriers to improved performance and/or validate a problem or measure conformance to standards. Oversee delegated activities by: establishing performance standards; monitoring performance through regular reporting; and evaluating performance annually. Evaluate under and over-utilization, continuity, and coordination of care through a variety of methods and frequencies based upon members needs. These methods include, but are not limited to, an annual evaluation of: medical record review; rates of referral to specialists; hospital discharge summaries in office charts; communication between referring and referred-to physicians; quarterly analysis of member complaints regarding difficulty obtaining referrals; identification and follow-up of non-utilizing members; profiles of physicians; rates of referrals per 1000 members; and performance measurement of practice guidelines. Coordinate QI activities with all other activities, including, but not limited to, the identification and reporting of risk situations, the identification and reporting of adverse occurrences from UM activities, and the identification and reporting of potential quality of care concerns through complaints and grievances collected through the Member Services Department. Evaluate the QI Program Description and Work Plan at least annually and modify as necessary. The evaluation addresses: a description of completed and ongoing QI activities that address the quality and safety of clinical care and the quality of services; trending of measures to assess performance in quality and safety of clinical care and the quality of service indicator data; analysis of the results of QI initiatives, including barrier analysis that evaluates the effectiveness of QI interventions for the previous year (demonstrated improvements in the quality and safety of clinical care and in the quality of services); an evaluation of the overall effectiveness of the QI program, including progress toward influencing safe clinical practices throughout the network that determines the appropriateness of the program structure, processes, and objectives; recommendations that are used to re-establish a Work Plan for the upcoming year which includes a schedule of activities for the year, measurable objectives, and monitoring of previously identified issues, explanation of barriers to completion of unmet goals, and assessments of goals. Implement and maintain health promotion activities and disease management programs linked to QI actions to improve performance. These activities include, at a minimum, identification of highrisk and/or chronically ill members, education of practitioners, and outreach programs to members. Maintain accreditation through the National Committee for Quality Assurance (NCQA) or other national accrediting body as appropriate. 5 QIP 2015

12 Scope of Quality Improvement Program Quality Improvement Program Description The QIP provides for the review and evaluation of all aspects of health care, encompassing both clinical care and service provided to external and internal customers. External and internal customers are defined as Members, practitioners, employers, governmental agencies, and Community Health Group employees. All departments participate in the quality improvement process. The Chief Medical Officer and/or the Director, Corporate Quality integrate the review and evaluation of components to demonstrate the process is effective in improving health care. The measurement of clinical and service outcomes and member satisfaction is used to monitor the effectiveness of the process. The scope of quality review will be reflective of the health care delivery systems, including quality of clinical care and quality of service. All activities will reflect the member population in terms of age groups, disease categories and special risk status. The scope of services include, but are not limited to, services provided in institutional settings, ambulatory care, home care and behavioral health (as provided by product line), and services provided by primary care, specialty care and other practitioners. Annual Review and Update of Quality Improvement Program The purpose of the annual QIP evaluation by the CorpQIC is to determine if quality improvement processes and recommendations made throughout the year result in demonstrated quality improvements in health care, disease prevention and the delivery of health care services to members. The annual evaluation assesses whether the QIP activities are systematically tracking improvement projects, resulting in improved clinical care and services, and providing appropriate follow-up of corrective actions to monitor their effectiveness. The CorpQIC is responsible for assessing reports, analyzing study and survey findings, and identifying areas of care which demonstrate improvement, and other areas which may still require interventions. Once a determination is made, the program plan is evaluated to see if certain processes require modification. A final report, including QIP program recommendations is submitted to the Board of Directors for annual approval. The following aspects of the Corporate Quality Department activities are assessed during the annual plan evaluation: Ongoing surveillance of quality indicators for the year; Quality improvement projects (goals and objectives) for the year; Tracking of previously identified issues requiring continued surveillance; Quality Improvement review of the QIP and outcome results from the previous year; Evaluation and modification, if necessary, of the QIP for the upcoming year; Implementation of the quality improvement strategy; Promotion of the development of an effective quality improvement program based on quality improvement strategies; Completion of the work plan in a timely basis; Determination if additional resources are necessary to accomplish the quality improvement strategy; and Recommendations for needed changes in the quality improvement program strategy or administration. QIP

13 Practitioners and members are notified annually that a summary of the QIP is available upon request. This summary includes information about the QIP s goals, processes, and outcomes as they relate to member care and service. Organizational Structure Oversight of the Quality Improvement Program is provided through a committee structure, which allows for the flow of information to and from the Board of Directors. An organizational chart is shown in Appendix A. Role of the Chief Medical Officer The Chief Executive Officer has appointed the Chief Medical Officer as the designated physician to support the Quality Improvement Committees outlined in this program by providing day to day oversight and management of quality improvement and credentialing activities. The Chief Medical Officer is responsible for: All activities requiring day-to-day physician involvement. The Chief Medical Officer may delegate performance of any of these responsibilities to other physicians within the network. Directing the Health Care Services Division and the various functions under its umbrella, including Quality Improvement, Credentialing, Clinical Review, Preventive Health, Behavioral Health Services (as covered by product line) and Pharmacy. The Chief Medical Officer consults with a contracted psychiatrist (designated behavioral health care practitioner), as necessary, for behavioral health issues. Communicating with the Board of Directors (Board) information from the Corporate Quality Improvement Committee (CorpQIC), the Clinical Quality Improvement Committee, (CQIC), the Credentialing Sub-Committee, the Utilization Management Committee (UMC), and the Pharmacy and Therapeutics Committee (P&T). Communicating feedback from the Board to the above listed committees. Serving as chair for the CQIC, the Credentialing Sub-Committee and the Technology Assessment Sub- Committee. Serving as co-chair for the CorpQIC, UMC, P&T and Benefits Interpretation committees. Overseeing meeting preparations for the above committees, educating committee members regarding the principals of quality improvement, keeping the committees and corporation current with the regulations and standards of the California Department of Health Care Services, Center for Medicare and Medicaid Services (CMS) and NCQA. Attending the Service Quality Improvement Committee (SQIC) meetings as needed and serving as advisor to the committee. Ensuring that the goals, objectives and scope of the QIP are interrelated in the process of monitoring the quality of clinical care, clinical safety and services to members. The Chief Medical Officer will not be influenced by fiscal motives in making medical policy decisions and establishing medical policies. Ensuring that a review and evaluation of the components of the QIP are performed annually in order to demonstrate that the process is effective in improving member care, safety, and services. Providing oversight to the implementation of the Quality Improvement Program (QIP). Guiding the formulation of quality indicators and clinical care guidelines in collaboration with network practitioners. Providing direct oversight of the credentialing and re-credentialing processes. 7 QIP 2015

14 Developing or approving policies and procedures for quality improvement, credentialing, preventive health, utilization management, pharmacy management and behavioral health. Reviewing aggregated outcomes from member complaints and grievances, member satisfaction surveys and practitioner satisfaction surveys. Overseeing the development of member and practitioner education in relation to QIP issues. Ensuring that quality of care is a component in all policy development related to health care services. Communicating directly with practitioners on any issues of the QIP to include quality of care, peer review, credentialing, or clinical care guidelines. Assisting the senior management team in the analysis, design and implementation of interventions to improve health care service delivery. Serving as an advisor to the Member Appeals Committee. Communicating information and updates regarding the QIP to Community Health Group leadership and staff via General Staff meetings, senior management team meetings, and other internal meetings. Delegating staff from other divisions to perform QI Program activities through the agreement of appropriate division chief. Designated Behavioral Health Practitioner Community Health Group utilizes a contracted network psychologist as the designated behavioral health practitioner for the QIP. The designated behavioral health practitioner advises the Clinical Quality Improvement Committee to ensure that the goals, objectives and scope of the QIP are interrelated in the process of monitoring the quality of behavioral health care, safety and services to members. Lines of Communication and Informational Flow Methods of communication include, but are not limited to, quality improvement reports, oral presentations and discussions, memorandums, policies and procedures and meeting minutes. Community Health Group monitors providers through quality monitors and on-site inspections and audits. The Director, Corporate Quality is the focal point for convergence of quality improvement related activities and information. The Director, Corporate Quality is responsible for the coordination and distribution of all quality improvement related data and information. The Corporate Quality Improvement Committee reviews, analyzes, makes recommendations, initiates action, and/or recommends follow-up based on the data collected and presented. The Chief Executive or the Chief Medical Officer communicates the CorpQIC s activity to the Board. The Board reviews the QI activities. Any concerns of the Board are communicated back to the source for clarification or resolution. (See Appendix B) QIP Committees Members For staff participants, qualifications and term of service as a committee member is determined by the duration of time a staff member holds the position, which initially qualified him/her for Committee membership (i.e., term of service continues as long as the Director, Corporate Quality holds his/her position which is also a designated position on the CorpQIC). Selected contracted practitioners and providers are invited to serve as members of a QIP Committee by the chairperson or co-chair. Selection is based on the following attributes: QIP

15 Availability/accessibility Board certification Communication skills/diplomacy Credentials/re-credentials verification Interest/enthusiasm Knowledge/expertise Managed care knowledge/experience Medical/surgical experience Peer/personal recommendation Previous quality committees experience QM audit results greater than average Reputation/ethical standards Specialty type A practitioner representative selected to participate on any QIP Committee continues to serve as long as she/he continues to qualify as a contracted practitioner whose specialty is required on the Committee panel and meets acceptable standards of behavior, with the following exceptions: Practitioner requests voluntary removal or Involuntary request for removal may be made when a provider: is no longer qualified is repeatedly unavailable (unexcused absences from three consecutive meetings) develops a conflict of interest behavior is disruptive and not conducive to effective, professional discussions and performance of business fails to meet QIP expectations QIP Committees Meetings The Corporate Quality Improvement Committee and subcommittees convene at regularly scheduled meetings, or more often if the chairperson deems it necessary; minimum frequency for CorpQIC meetings will not extend beyond a quarterly basis. A quorum consisting of either four members or 50% of the members, whichever is less, must be present for any QIP committee to conduct business, unless the chairperson has attempted to reschedule and notify participants of the meeting and a quorum still does not exist. If a quorum cannot be assembled within thirty (30) minutes of the scheduled meeting, those in attendance will select an alternate date and time. If at the alternate meeting time a quorum is still not present and cannot be obtained within thirty (30) minutes, the committee may either elect to meet and conduct business or disband. The chairperson, with the assistance of the co-chair, is ultimately responsible for notifying committee members about the meeting schedules. Reminder phone calls will be placed to the committee members a minimum of three (3) days prior to the scheduled meeting to encourage participation. An agenda and any necessary reading materials will be mailed to participants in advance to expedite the meeting time and prepare for discussion. 9 QIP 2015

16 QIP Committees Minutes Comprehensive, accurate minutes are prepared and maintained for each QIP regular or ad hoc meeting. Minutes include at a minimum, the name of the committee, date, list of members present, and the names and titles of guests, if applicable. The minutes reflect all decisions and recommendations, including rationale for each, the status of any activities in progress, and a description of the discussions involving recommended studies, corrective action plans, responsible person, follow-up and due date. Minutes will be maintained in a confidential secure file. Each committee chairperson will sign and date all minutes at the time of approval. Minutes of QI Program committees meetings are provided for review to the: Committee members, Board of Directors, and Regulatory bodies (as required and applicable). Committee Agenda The QIP Committees agendas shall follow the basic outline: Review of Minutes Unfinished Business Ongoing Reports Review of Protocols/Policies New Business Copies of all minutes, reports, data, medical records and other documents used for quality or utilization review purposes, are maintained in a manner that will ensure confidentiality of the members and providers involved in each case. Access to these records is restricted to the QIP committees members and selected administrative personnel as deemed necessary (i.e., CEO, legal staff/counsel, Board). All sensitive information, medical records and CorpQIC findings are maintained in locked files. QIP reports, minutes, audit results and other Quality Improvement documentation are only distributed for review to the: Chief Medical Officer Chief Executive Officer Board of Directors QIP Committee members Regulatory bodies (as required and applicable) All distributed copies are collected and destroyed after review; originals are maintained in secured files by committee chair and/or co-chair. Corporate Quality Improvement Committee (CorpQIC) The Corporate Quality Improvement Committee establishes strategic direction, recommends 2 policy decisions, analyzes and evaluates the results of QI activities, and ensures practitioner participation in the QI program through planning, design, implementation, or review. The CorpQIC ensures that appropriate actions and follow-up are implemented and evaluates improvement opportunities. The CorpQIC meets and reports at least quarterly to the Board s Quality of Care Committee. The CorpQIC is a multidisciplinary committee, the membership includes: QIP

17 Chief Executive Officer, Chair Chief Medical Officer, Co-chair Chief Regulatory Affairs and Human Resources Officer Chief Information Systems Officer Director, Corporate Quality Support Staff and Guests will be invited to attend the meetings as reporting requirements dictate. Responsibilities and Functions: Review the QI Program Description that establishes strategic direction for Community Health Group and forward to the Board for approval. Evaluate the Quality Work Plans, which includes providing feedback and recommendations to the appropriate sub-committee or department and forward to the Board for approval. Evaluate the effectiveness of the QI Program with input from other communities and departments annually. Receive, review, and analyze status reports on the implementation of Work Plans, including aggregate trend reports and analysis of clinical and service indicators. Appoint subcommittees and ad hoc committees as needed. Ensure that system-wide trends are identified and analyzed. Ensure that quality improvement efforts are prioritized, resources are appropriate, and resolutions occur. Prioritize quality improvement efforts and assure that resources are allotted. Approve Quality Improvement Program policies. Ensure appropriate oversight of delegated activities. Ensure integration, coordination, and communication among committees reporting to CorpQIC. Clinical Quality Improvement Committee (CQIC) The Clinical Quality Improvement Committee advises the CorpQIC of the QIP program activities and procedures performed to monitor and evaluate the quality, safety, and appropriateness of health care. The Clinical QIC meets quarterly or more frequently as needed and reports to the CorpQIC quarterly. Responsibilities: Analyzing demographic and epidemiological data Identifying risk member populations Selecting disease management clinical practice guidelines and quality activities Developing, communicating and implementing clinical practice guidelines based on current medical standards of care. These guidelines include, but are not limited to, standards instituted and approved by the American Academy of Family Physicians, American Board of Internal Medicine, American Academy of Pediatrics, American Academy of Ophthalmology, American College of Obstetricians and Gynecologists, California's Child Health and Disability Prevention Program, Health Care Effectiveness Data and Information Set (HEDIS) and United States Preventive Services Task Force. Identifying sub-optimal care through the analysis of data referred from all departments QIP 2015

18 Reviewing and approving identified trends and opportunities for improvement and recommendations for strategies to prevent adverse outcomes. Identifying practitioners/providers not complying with Community Health Group medical care standards, service standards, guidelines and/or policies and procedures. Reviewing and approving action plans for practitioners/providers in collaboration with companywide departments. Members The Clinical Quality Improvement Committee consists of the representatives listed below. Regular physician participants determine the most appropriate follow-up action to take when physician peer review issues are confirmed. There must be a minimum of three physicians in attendance to conduct committee business. Physician attendance may be in person or telephonic. Additional participants and staff representatives provide useful information and/or serve as liaisons to their respective departments. Community Health Group s Chief Medical Officer, co-chair Community Health Group s Director, Corporate Quality, co-chair Contracted IPA and medical group representatives Selected contracted, practicing physicians with diverse specialty representation (including at least two (2) who are primary care physicians (PCPs) representing Internal Medicine, Family Practice, and/or Pediatrics Obstetrician/Gynecologist Behavioral Health Physician Consultant, as needed Non-Physician Medical Practitioner Community Health Group Staff Members: Medical Director Director of Pharmacy Services Director of Utilization Management Services Provider Relations representative Corporate Quality Analyst Corporate Quality Specialist Credentialing Services Manager Physicians of other specialties as needed Ancillary Services Providers (radiology, physical therapy, etc.), as needed Major Responsibilities Chief Medical Officer: Serves as Committee co-chairperson Reports CQIC activities to the CorpQIC Director, Corporate Quality: Serves as Committee co-chairperson Reports CQIC activities to the CorpQIC, in the absence of the Chief Medical Officer Conducts literature searches to help develop potential indicators based on accepted standards of care Develops mechanisms to collect, store and profile data Reports summaries of site inspections; quality indicator screens; medical records audits; Member complaints and grievances; environmental health and safety/infection control issues; risk management issues and other issues as indicated to the Committee QIP

19 Credentialing Sub-Committee The Credentialing Sub-Committee is a sub-committee of the CQIC. This sub-committee is responsible for the review of credentialing files and makes decisions regarding credentialing and recredentialing of practitioners. The Credentialing Sub-Committee makes decisions regarding provider organizational credentialing/recredentialing. The sub-committee is responsible for the review of performance data at the time of recredentialing and making on-going contract recommendations as a result of recredentialing. The Credentialing Sub-Committee serves as the practitioner Peer Review and Appeals Committee. In this role the committee makes a reasonable effort to obtain the facts, provide adequate notice and conduct hearing procedures for health care practitioners. The members are the practitioners from the CQIC. The committee meets at least quarterly prior the CQIC and conducts telephonic meetings monthly between the quarterly meetings. The Chief Medical Officer is the chairperson. The functions of the Credentialing Committee are: Review, recommend, and approve procedures for practitioner/provider credentialing /recredentialing. Review and approve practitioner/provider credentials. Review and approve a practitioner/provider profile with input from all departments that analyze performance in conjunction with the recredentialing process. Review and approve credentialing/recredentialing standards/policy and procedures. Review and approve quality of care and service indicators for recredentialing. Review of delegated credentialing performance. 4 Pharmacy and Therapeutic (P&T) Committee The P&T Committee meets and reports to the CorpQIC quarterly. The Chief Medical Officer and Director of Pharmacy Services serve as co-chairs. The membership includes: 5 Chief Medical Officer Director of Pharmacy Services Network primary and specialty care practitioners Network pharmacy directors Pharmacy benefit management company representative Responsibilities and Functions Formulating policies on the evaluation, selection, distribution, use and safety procedures relating to medication therapy Developing and maintaining the Drug Formulary Monitoring activities related to the Formulary Exception Policy Monitoring prescribing practices and drug utilization for appropriateness Submitting a quarterly report to the CorpQIC of the status of all activities Utilization Management Committee (UMC) The Utilization Management Committee provides direction to and oversight of the Utilization Management Program. The UMC meets quarterly and reports to the CorpQIC quarterly. The Chief 13 QIP

20 The UMC is a multi- Medical Officer and Director of Utilization Management serve as co-chairs. disciplinary committee whose members include: Chief Medical Officer Network primary care and specialty practitioners Contracted IPA and medical groups representatives Director of Pharmacy Services Corporate Quality Representative Responsibilities and Functions Reviews and approves the UM Program Description that establishes direction for the organization Receives, reviews and analyzes utilization reports on the progress of the UM Program Conducts new technology assessment Reviews recommendations for delegation of utilization management and makes recommendations to the CorpQIC Formalizes UM policies and procedures Reviews, approves and distributes medical criteria and criteria for review at least annually Monitors continuity and coordination of care Conducts under/over utilization monitoring on practitioner specific and organizational-wide dimensions Evaluates satisfaction with the UM Program using member and practitioner input Technology Assessment Sub-Committee The Technology Assessment Sub-Committee (TASC), a sub-committee of the Utilization Management (UM) Committee, meets at least four times each year, with ad hoc meetings as necessary, or called by the chairperson. TASC reviews and assesses existing and emerging medical technologies, drugs, procedures and therapeutic modalities on an as-needed basis. The Chief Medical Officer is the chairperson and members include: 7 Community Health Group Chief Medical Officer, who will chair the sub-committee Director of Utilization Management Director of Pharmacy Services Corporate Quality Representative Clinicians who are credentialed and contracted by Community Health Group for both primary care and specialty care Clinicians and external experts who are not credentialed and contracted may be invited as guests of the sub-committee Service Quality Improvement Committee (SQIC) The Service Quality Improvement Committee monitors and evaluates the quality, safety, and appropriateness of non-clinical services to members, practitioners and providers and operations of the organization. The Service Quality Improvement Committee meets at least quarterly and reports to the CorpQIC quarterly. The Chief Regulatory Affairs and Human Resources Officer is the chairperson. The Service QIC membership includes: 8 QIP

21 Chief Regulatory Affairs and Human Resources Officer Chief Information Systems Officer Director of Health Plan Operations Director, Corporate Quality Director of Pharmacy Services Director of Utilization Management Director of Contract Administration Regulatory Affairs/Compliance Manager Member Services Auditor/Trainer Responsibilities and Functions Responsibilities of the Service QIC include reviewing and making recommendations for interventions to improve all service activities relative to: Complaints Grievances Member and Provider Appeal trends Telephone and turnaround time standard performance Access and Availability Claims service standards Enrollment service standards Plan Operations Member and practitioner satisfaction/dissatisfaction as identified by surveys including monitoring of PCP change requests and results of access and availability monitoring Committees and departments reporting to Service QIC are: Committees Member Appeals Transition Task Force Departments Claims Client Services Member Services Clinical Management Contracts Provider Relations Information Systems Corporate Quality Member Appeals Committee The Member Appeals Committee meets on an ad hoc basis depending on the need. Reports are generated in the aggregate and by category of Grievance/Appeal and reported to the Clinical and Service QICs, the CorpQIC, the Public Policy Committee and the Board of Directors on a quarterly basis. Membership includes: 9 Chief Medical Officer Appeals Supervisor 15 QIP 2015

22 Chief Regulatory and Legal Affairs Officer Director of Health Plan Operations Responsibility and Function The Appeals Committee provides for and defines the mechanism for processing appeals from members based on a fair and timely manner in accordance with state and federal regulations. Corporate Compliance Committee The purpose of the Corporate Compliance Committee is to address fraud prevention and detection and corporate confidentiality compliance. The committee oversees the Anti-Fraud Plan and determines appropriate responses to reported or suspected fraud. The Corporate Compliance Committee reports operational activities to the Chief Executive Officer and a summary report to the CorpQIC quarterly. The Corporate Compliance Committee meets on an ad hoc basis, but at least quarterly. The members are: 10 Regulatory Affairs/Compliance Manager, Chair Compliance Officer Chief Regulatory Affairs and Human Resources Officer Chief Financial Officer Director of Health Plan Operations Director Corporate Quality Director of Pharmacy Services Director of Utilization Management Director of High Risk Case Management System Manager/Privacy Officer Corporate Quality Analyst Public Policy Committee (Member Advisory Committee) The Public Policy Committee s purpose is to assure an avenue for member involvement in the development of educational materials, improvement of the customer service interface and in making recommendations for system changes as they affect the member. The goal of the committee is to provide a forum for member input, and to increase consumer satisfaction and member retention. The committee meets and reports to the CorpQIC and the Board of Directors quarterly. The Director of Utilization Management Services is the co-chair of the meetings with the Board of Directors representative. The membership includes: 11 Member of the Board of Directors Director of Health Plan Operations Members representing each product line Network Primary Care Practitioner Member Services representative Responsibilities and Functions Assure member input to the quality improvement process for user friendly access. Recommend to practitioners, solutions and strategies for improving membership materials and member access issues. Review prospectively new material under development. Review complaint/grievance trends for clarity of member information to facilitate changes to the system, which will produce positive outcomes. QIP

23 Delegation Oversight Committee The Delegation Oversight Committee provides a formalized mechanism to monitor and act on all delegated activities. The Committee meets at least quarterly and reports to the Corporate Quality Improvement Committee and other appropriate committees as necessary. The Chair is the Chief Regulatory Affairs and Human Resources Officer. Membership includes: 13 Chief Financial Officer Director of Pharmacy Services Regulatory Affairs/Compliance Manager Director of Health Plan Operations Director of Contract Administration Credentialing Services Manager Behavioral Health Advisory Committee The Behavioral Health Advisory Committee establishes strategic direction and recommends policy decisions relating to Community Health Group s Behavioral Health Program. The Behavioral Health Advisory Committee meets and reports at least bi-annually to the Corporate Quality Improvement Committee (CorpQIC). The Behavioral Health Advisory Committee is a multi-disciplinary committee, chaired by the Chief Medical Officer. The Committee s membership includes: Chief Medical Officer Medical Director Director of Pharmacy Services Behavioral Health Services Manager Director, Corporate Quality Staff Psychologist Behavioral Health Consultant Contracted Psychiatrist Contacted Psychologist Contracted Licensed Clinical Social Worker Contracted Marriage Family Therapist Contracted Pediatrician/PCP Psychiatric Hospital Utilization Review RN Mental Health Consumer Advocate Public Mental Health Representative/United Behavioral Health Responsibilities and Functions Review of Authorization Criteria and Process. The Committee, in conjunction with the UM Committee, is charged to develop, review, evaluate and update Community Health Group s criteria and process for authorizing Behavioral Health Services to members. Advisory Panel. Each member of the Committee serves in an advisory capacity to the Chief Medical Officer when such services are needed, particularly on an emergent or urgent basis. Continuity and Coordination of Care with Medical Practitioner. The Committee collaborates with Community Health Group and primary care practitioners to monitor and improve coordination between medical and behavioral health care. This coordination is accomplished through review, recommendation, and approval of: QIP 2015

24 mechanisms for exchange of information guidelines for diagnosing, treating and referring of behavioral health disorders commonly seen in primary care appropriate uses of psychopharmacological medications protocols for management of treatment access and follow-up for members with coexisting medical and behavioral disorders, and primary and secondary preventive behavioral health program implementation. Review of Aberrant Practice Patterns. The Committee reviews potential aberrant practice patterns or potential fraudulent activity identified by the Behavioral Health Department, Case Management Department, Claims Department, Pharmacy Services Department, Preventive Services Department and/or Corporate Quality Department and recommends corrective actions and/or policies and procedures to prevent recurrence. Quality of care issues are referred to the Quality Improvement Committee for action or review, tracking and trending. Recommendation and Implementation of Corrective Action. The Behavioral Health Advisory Committee may recommend corrective action, including practitioner sanctions, when trends or patterns of inappropriate health care resource use are identified. Such corrective actions may include formal or informal educational programs. The "Provider Fair Hearing" policy outlines procedures for imposing sanctions. Statistical Outcome Studies. The Behavioral Health Advisory Committee, in conjunction with the Utilization Management Committee, Quality Improvement Committee and Pharmacy and Therapeutics Committee produce statistical outcome studies utilizing information obtained from Community Health Group's management information system that: o support the process of evaluation and continuous quality improvement of the clinical process; o identify those clinical processes which are statistically more effective than others in order to o provide a resource for clinical quality improvement; and disseminates appropriate health care information to practitioners that will assist in promoting improved quality and cost effectiveness in health care. Establishment of Behavioral Health Studies and Criteria. The Committee may develop special studies to identify at risk populations for Behavioral Health disease management programs and to identify utilization and/or quality problems that affect the outcome of member care wellness. o o o Medical records shall be provided for the Committee's review when there is evidence of aberrant use of Plan resources. If a specialty area is not represented on the Committee, the Chief Medical Officer or the Committee may delegate the review to a qualified specialist or request a local qualified specialist to participate on the Committee for the review. Quality of care issues shall be referred to the Quality Improvement Committee for action or review and trending. Recommendations shall be made regarding population and disease management programs. Other Meetings The following meetings are designed for information sharing. Issues requiring resolution are referred to the appropriate committee, sub-committee or taken to the CorpQIC for assignment: Administrative Meeting General Staff Meeting Case Managers Meeting Leadership Strategies Team (LDT) Meeting Operations Meeting QIP

25 Corporate Quality Department The Corporate Quality Department reports to the Chief of Operations. department include: Responsibilities of the provide staff support to the Corporate Quality Improvement Committee, Clinical Quality Improvement Committee, and Sub-Committees; develop initial drafts of the QI Program documents for review and approval by the CorpQIC; develop a Work Plan identifying the responsibilities of the operations that support the program implementation; review and evaluate the Work Plans and quarterly reports of the sub-committees reporting to the CorpQIC; participate in the initial evaluation of potential delegates, reviewing and evaluating delegates reports and participate in the annual review of the delegates; assist in data collection for selected components of contractual reporting requirements for external review agencies; develop and implement systematic data collection methodologies; assist in the development of research design and methodologies for disease management programs; monitor the QI Program to assure compliance with regulatory and accrediting agency requirements; and assist in the development of company-wide policies and procedures related to Quality Improvement. Credentialing Department The Credentialing Department reports to the Director of Contract Administration, and is responsible for developing policies, procedures and forms used in the credentialing and recredentialing of practitioners. The Credentialing Unit assists the Contracts Department in development of polices, procedures and forms used in the credentialing and recredentialing of health care delivery organizations. The credentialing staff implements the policies and procedures, including gathering all applications, primary source verification, and presents a completed file for the Chief Medical Officer s review and action by the Credentialing Sub-Committee. Role of Participating Practitioners Participating practitioners serve on the QIP Committees as necessary to each committee s function. Through these committees activities, network practitioners: Review, evaluate and make recommendations for credentialing and recredentialing decisions; Review individual medical records reflecting adverse occurrences; Review and provide feedback on proposed medical guidelines, preventive health guidelines, clinical protocols, disease management programs, quality and HEDIS results, new technology and any other clinical issues regarding policies and procedures; Review proposed QI study designs; and Participate in the development of action plans and interventions to improve levels of care and service. 19 QIP 2015

26 Conflict of Interest Quality Improvement Program Description Health care providers serving on any QIP Committee, who are/were involved in the care of a member under review by the committee, are not allowed to participate in discussions and determinations regarding the case. In addition, committee members cannot review cases involving family members, providers with whom they have a financial or contractual affiliation or other similar conflict of interest issues. Prior to participating in any QIP activities, committee members are required to sign a Conflict of Interest statement, which is maintained on file in the Corporate Quality Department. (See Appendix C) Confidentiality Because of the goals and objectives of the QIP, sensitive and confidential information is often discussed during Clinical QIC and Credentialing Sub-Committee meetings. All participants understand that information and parties under investigation or discussion by the Committee members are considered confidential. Prior to participating in Clinical QIC and Credentialing activities, committee members are required to sign a Confidentiality Statement (refer to Appendix C), which is kept on file in the Corporate Quality Department. Behavioral Health Services Community Health Group s behavioral health management philosophy is to provide behavioral health care services to members in order to achieve the best possible clinical outcomes with the most efficient use of resources. It is our philosophy that timely, high-quality care, delivered by the appropriate provider in the least restrictive treatment setting is the key to achieving that objective. The goal of our Behavioral Health Program is to return our members to healthy, productive lifestyles as quickly as possible and to maintain that level through careful recovery. Specialty Mental Health, meaning treatment for a member with a Serious Mental Illness or Serious Emotional Disturbance is contractually carved-out of Medi-Cal Managed Care. These services which includes inpatient and outpatient care are covered by the San Diego County Mental Health Plan. For Cal MediConnect, Community Health Group covers all medically necessary and Medicare covered behavioral health services including inpatient care, partial hospitalization, intensive outpatient programs and outpatient treatment. For Medi-Cal, Community Health Group covers outpatient treatment for members with a mild to moderate mental health condition. All Federal and State Mental Health Parity Act regulations are followed. For covered behavioral health benefits, Community Health Group has no limitations on number of visits, no limits on days in a psychiatric hospital and no co-pays. Community Health Group (CHG) has an organized Behavioral Health Care Division, reporting to the Medical Director under the direction of the Chief Medical Officer. A contracted psychologist is the designated behavioral health care practitioner, who consults with a contracted psychiatrist, and works with the CHG Chief Medical Officer. QIP

27 A network that is directly contracted and credentialed by Community Health Group provides behavioral health and substance abuse care. Our behavioral health services and early intervention techniques strive to assure that behavioral health care treatment meets accepted national standards and is delivered by appropriate practitioner or provider in the most appropriate setting. Our services include: Members with our Behavioral Health Care benefit may have care without the need of primary care referral; they can self-refer for needed care. Provide utilization management, quality improvement, and network management operations based on standards set by applicable state and federal law, as well as the following organizations: National Committee for Quality Assurance, AAHC/Utilization Review Accreditation Committee (URAC), the American Psychiatric Association, and the American Academy of Child and Adolescent Psychiatry. Through contracts with all the emergency departments in the county, offer 24-hour crisis intervention and assessment of treatment needs. Determine the proper modality, duration, setting and level of care as defined by nationally approved standards. Deliver effective counseling services through a comprehensive network of well-known psychiatrists, psychologists, marriage and family therapists, and social workers with concentrated areas of expertise. Manage treatment resources to secure high-quality, cost-effective care. Monitor member needs for treatment plan modification. Facilitate optimal discharge planning and follow-up. Coordinate care between key specialists and other treatment providers. Provide accurate information management and monitor reporting. Member focus processes were developed and are monitored to ensure that behavioral health needs are handled in a compassionate, culturally appropriate, and effective manner. To facilitate these processes, the following are incorporated into the care management program: Qualified behavioral health intake specialists supported by licensed clinical staff and advanced management systems to facilitate a clinically appropriate referral; Telephone access to on-site clinicians 24 hours a day, 365 days a year for crisis intervention through contracts with acute care hospitals; and Referral to network of credentialed practitioners based on the member's presenting problem, as well as geographic, special language or cultural preferences. Continuity and coordination of care between the medical delivery system and behavioral health care is enhanced in the following manner: Monitoring the exchange of information between medical and behavioral health practitioners. Encouraging the appropriate diagnosis, treatment and referral of behavioral health care disorders commonly seen in primary care. Tracking appropriate uses of psychopharmacological medications. Managing treatment access and follow-up for members with coexisting medical and behavioral disorders. Establishment of a post-partum depression preventive behavioral health program. The Behavioral Health Advisory Group is a multi-disciplinary committee that includes behavioral health and primary care practitioners. The group meets quarterly to address and monitor behavioral health issues and encourages input from practicing physicians in the network. 21 QIP 2015

28 Member Safety Quality Improvement Program Description Community Health Group is committed to an ongoing collaboration with network practitioners, providers and vendors to build a safer health system. This is accomplished through established quality initiatives that promote best practices, tracking outcomes and educating patients, providers and members. The goals of the safety program include but are not limited to: Informing and educating members, practitioners and providers of issues affecting member safety Identifying and evaluating strategies for analyzing events, promoting reporting and improving patient safety Placing provider safety information collected from The Leapfrog Group web page and making this performance data publicly available for members, caregivers, and practitioners on the CHG web site under Hospital Safety. The CorpQIC, with input from its reporting committees, develops and implements a process that addresses improving member safety. The goal of the process is to foster a supportive environment to aid practitioners and organizational providers in improving safety in their practice. Activities that may be included in this process are: Case Management Programs Assists in the coordination of managed care efforts to reduce or prevent omission or duplication of orders when multiple providers are involved, Monitors Emergency Room utilization beyond a threshold of two or more times in any quarter to identify the lack of primary care, the absence of coordinated care, potential drug interactions, unnecessary testing and treatments, omission or duplication of care, or patient non-adherence with a care plan. Drug Safety CHG monitors for appropriate medication use to ensure the safety of members. These techniques include, but are not limited to: Potential drug and drug disease interactions; Analyzing pharmacy data to identity polypharmacy, potential adverse drug reactions, inappropriate medication usage, excessive controlled substance usage and voluntary drug recalls; Assuring that affected members and practitioners are notified of FDA or voluntary drug alerts; Notification and education of members and practitioners of other identified events; Conducting pharmacy system edits to assist in avoiding medication errors; and Working with contracted pharmacies to assure a system is in place for classifying drug-drug interactions and/or notifying dispensing providers of specific interactions when they meet CHG s severity threshold. Utilization Management The concurrent review process has established a medical management process which follows identified participants throughout the healthcare delivery system to ensure optimal delivery of care. Health Management Programs Works to assist, communicate, and educate patients and practitioners in standards of care in all aspects of specific disease processes. These programs are especially important to help identify over and under utilization, patient non-compliance, and care that does not meet the standards, thus assisting to reduce adverse medical events. Clinical practice guidelines go hand in hand with the disease management QIP

29 programs and address patient safety by communicating evidence based standards of care to practitioners and members. Quality Improvement Establishes standards for medical record documentation Conducts an on-going medical review process that evaluates key components of documentation to address patient safety Establishes a rigorous process for investigation and resolution of complaints, especially quality of service and care complaints against practitioners and providers Monitors quality of care indicators to identify patterns and/or trends Strives to contract only with hospitals and ancillary providers that are JCAHO accredited or other nationally recognized accreditation organization Administrative Patient Safety Activities In addition to the activities listed above, CHG participates in many other patient safety activities. These activities include, but are not limited to: Conducts office site reviews as part of the initial practitioners credentialing process Conducts a rigorous credentialing and recredentialing process to ensure only qualified practitioners and organizations provide care in the network Establishes a process that monitors the continuity and coordination of care between the medical delivery system and behavioral healthcare, and between the medical delivery system and health delivery organizations Encourages participating hospitals to voluntarily report their data to Leapfrog Mechanisms for communication include: CHG member and practitioners web site Communications to providers and practitioners through the Provider Alert Newsletters Drug safety recalls, refill history and dosage alerts Safety specific letters to individual practitioners, providers or members Monitoring and Evaluation Patient safety activities are monitored continuously and will be trended and reported quarterly. The Patient Safety Program will be evaluated annually as part of the annual quality improvement program evaluation. Quality Issue Identification To provide overall quality functioning, each division and/or department will continually monitor specific important aspects of care. These aspects or activities of care and/or service include, but are not limited to: Access/Availability Continuity/Coordination Health and Pharmacy Management Systems Under/Over Utilization Behavioral Health Care 23 QIP 2015

30 Chronic/Acute Care High-Risk/High-Volume/Problem Prone Care Preventive/Health Care Member Satisfaction/Dissatisfaction (Customer Service) Member Appeals and Grievances Medical Record Documentation Clinical Practice Guidelines/Preventive Health Guideline Compliance Community Health Group Service Standards Individual Care Review Credentialing Provider Relations Claims Analysis Marketing Feedback Quality Monitors (Sentinel Events) Screening Community Health Group's Health Care Services staff will continually assess interactions with members health care systems for potential quality of care issues. Continual quality monitoring of members health care on a daily basis provides a methodology enabling the Health Care Services staff to identify indicators that may suggest the presence of less than optimal care. The following monitors identify the minimum health care areas for review of quality care problems: Unexpected death during hospitalization Complications of care (outcomes), inpatient and outpatient Reportable events for long-term care (LTC) facilities include but are not limited to falls, suspected abuse and/or neglect, medication errors, pressure sores, urinary tract infections, dehydration, pneumonia, and/or preventable hospital admissions from the LTC facilities. Reportable events for community-based adult services (CBAS) centers include but are not limited to falls, injuries, medication errors, wandering incidents, emergency room transfers, and deaths that occur in the CBAS center and unusual occurrences reportable pursuant to adult day health care licensing requirements. Protocol for Using Quality Monitors Screens Case Management and Referrals staff apply the quality monitor screens to each case reviewed during pre-certification and concurrent review. Contracted LTC facilities and CBAS centers must report all identified reportable events to the Director of Utilization Management. All potential quality issues are routed to the Corporate Quality Department. Corporate Quality staff access the Auth Scans system daily to review new Quality Monitor referral entries. The Corporate Quality staff, under the supervision of the Director Corporate Quality, determines the need for additional documentation, inpatient or ambulatory care, in evaluating the cause of potential quality of care. When it is decided that medical records are required, the Corporate Quality staff contacts the appropriate inpatient facility/ambulatory care site to obtain copies of the medical record. It may be necessary for a Corporate Quality staff member to visit the facility/site to review the record. When a case is identified to have potential quality of care issues, the Corporate Quality staff will present the case to the Chief Medical Officer for review. If the Chief Medical Officer identifies no quality of care QIP

31 problem, the case requires no further review. The case is routed back to the Corporate Quality staff who initiated the review for closure of the case. When the Chief Medical Officer agrees that a quality of care problem exists, he/she reviews the case, assigns a priority level, initiates corrective action, or recommends corrective action as appropriate. For case of neglect or abuse, follow-up/corrective action may include referrals to Child or Adult Protective Services. The case is then forwarded to the Clinical Quality Improvement Committee (CQIC). The CQIC reviews the case, the priority rating, and recommendations or actions implemented for corrective action and follow-up. The CQIC either approves the rating and recommended corrective actions or assigns a new rating and recommends additional or different corrective action and follow-up. In-Home Supportive Services (IHSS) Quality Monitoring Community Health Group will participate in the stakeholder workgroup established by the Department of Health Services, the State Department of Social Services, and the California Department of Aging to develop the universal assessment process, including a universal assessment tool, for home-and community-based services, as defined in subdivision (a) of Section The stakeholder workgroup shall include, but not be limited to, consumers of IHSS and other home- and community-based services and their authorized representatives, the county, IHSS, Multipurpose Senior Services Program (MSSP), and CBAS providers, and legislative staff. The universal assessment process will be used for all home-and community-based services, including IHSS. In developing the process, the workgroup shall build upon the IHSS uniform assessment process and hourly task guidelines, the MSSP assessment process, and other appropriate home- and community-based assessment tools. In developing the universal assessment process, a universal assessment tool will be developed that will facilitate the development of plans of care based on the individual needs of the recipient. The workgroup shall consider issues including, but not limited to, how the results of new assessments would be used for the oversight and quality monitoring of home- and community-based services providers. Community Health Group will work closely with the San Diego County IHSS Agency to develop an appropriate monitoring and oversight plan to adhere to quality assurance provisions and individual data and other standards and requirements as specified by the State Department of Social Services including state and federal quality assurance requirements. Referrals will also be made to appropriate agencies for follow-up and/or referrals will be made to local Adult and Child Protective Services agencies or law enforcement agencies (when appropriate). Quality Improvement Activities Long Term Care Facilities Monitoring of the quality of care provided to Community Health Group members, including those residing in LTC facilities, includes, but is not limited to, the following: Member complaint and/or grievance trends. Provider complaint and/or grievance trends. Case review of potential quality of care issue referrals triggered by quality monitors (sentinel events), or utilization management activities. Member satisfaction surveys. Focused review of topics, including those specifically related to special needs populations such as members residing in LTC facilities. 25 QIP 2015

32 Topics for review are identified through the monitoring process. Proposed study indicators shall be reviewed by the Clinical Quality Improvement Committee and approved prior to commencing the study. Initiation of quality improvement projects will be directed to the identified needs of members residing in LTC facilities. Focused quality improvement audits for members residing in LTC facilities are performed by the Concurrent Review Case Managers, or Corporate Quality Analysts, during on-site facility visits. Results of quality improvement activities are presented to the Corporate Quality Department for review, analysis and summarizing. LTC facilities are notified if there is a need to execute corrective action plans (CAPs). Follow-up reviews will be conducted at LTC facilities when CAPs are executed. Community Health Group assists in the identification and communication of potential quality of care issues with other agencies directly involved in coordination of services for Community Health Group members in LTC facilities, including the San Diego County Regional Center, Licensing and Certification, Medi-Cal Operations Division and the Ombudsman's Office. Referrals will also be made to appropriate agencies for follow-up and/or referrals will be made to local Adult and Child Protective Services agencies or law enforcement agencies (when appropriate). Cultural and Linguistic Objectives Community Health Group (CHG) will ensure that all services, both clinical and non-clinical, are provided in a culturally competent manner and are accessible to all members, including those with limited English proficiency, limited reading skills, hearing incapacity, or those with diverse cultural and ethnic backgrounds. All individuals providing linguistic services to CHG members shall be adequately proficient in the required language to both accurately convey and understand the information being communicated. This policy applies to CHG staff, providers, provider staff, and professional translators or interpreters. Responsibility Oversight of the provision of cultural and linguistic services is the responsibility of the Director of Utilization Management Services. Objectives Community Health Group offers programs and services that are culturally and linguistically appropriate by: Using practitioner and provider chart reviews and interviews to understand the differences in care provided and outcomes achieved to reduce health care disparities in clinical areas. Conducting patient-focused interventions with culturally competent outreach materials that focus on race/ethnicity/language specific risks to improve cultural competency in materials. Conducting focus groups or key informant interviews with cultural or linguistic minority members to determine how to better meet their needs to improve cultural competency communications. Providing information, training and tools to staff and practitioners to support culturally competent communication to improve network adequacy to meet the needs of underserved groups. Community Health Group has designated the Director of Utilization Management Services to provide oversight for meeting the objectives of service to a culturally and linguistically diverse population through the following: Translation services Interpretation services Proficiency testing for bilingual Spanish staff QIP

33 Cultural competency trainings such as: Medical Interpreting Workshops Interpreter Services In-service Older Adult Sensitivity Workshops Cultural Competency Workshops Provider newsletter articles on a variety of cultural and linguistic issues Health education materials in different languages and appropriate reading levels Provider office signage on the availability of interpretation services Complex Care (High Risk) Management Program The Complex Case (High Risk) Management Program (CCMP) activities promote a community based system of caring for members with chronic complex conditions and needs by: Encouraging members to participate in effective community programs. Developing and establishing partnerships with community organizations to support and develop interventions that fill gaps in needed services. The CCMP focus on addressing the needs of members with one or more of the following health issues: Physical disabilities, Developmental disabilities, Chronic conditions, and Mental illness. The CCMP promotes safe, high quality care through: Visible support of improvement at all levels of the organization and care delivery system, beginning with the Board and executive partners. Establishment of effective improvement strategies aimed at comprehensive system change. Encouragement of open and systematic handling of errors and quality problems to improve care. The CCMP empowers and prepares members to manage their health and health care by: Focusing and emphasizing that the member and his/her family are central in managing their health Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving, education, and follow-up Organize internal and community resources to provide ongoing self-management support to members The CCMP, in concert with the overall organization and care delivery system, assures the delivery of effective, efficient clinical care and self-management support by: Defining roles and distributing tasks among the health care management team members Using planned interactions to support evidence-based care 27 QIP 2015

34 Initiating chronic care/case management services for members with complex conditions Establishing mechanisms to ensure regular follow-up and ongoing reassessment of members needs by the care management team Promulgating care that is culturally and linguistically appropriate to members CCMP promotes clinical care that is consistent with scientific evidence and member preferences through the following: Promote and incorporate evidence-based guidelines whenever possible into daily care management Educate practitioners regarding evidence-based guidelines and provide information to members to encourage their participation Employ a variety of provider education and incentive methods Integrate specialist expertise and primary care The CCMP develops and implements systems to identify, monitor, track and trend member specific information, as well as aggregate population information to facilitate efficient and effective care by: Providing timely reminders for providers and members Identifying specific target populations for proactive care management Facilitating individual member care planning Documenting and sharing information with members and providers to coordinate timely care and services Monitoring the performance of practitioners individually and collectively, and the processes and systems used to render care and services The CCMP integrates case management and chronic care improvement strategies and measures with other quality measures, including HEDIS measures, as applicable, by: Establishing chronic care improvement measures that are in concert with HEDIS measures for diabetes, hyperlipidemia, immunizations, mammograms, etc., where applicable. Creating a database for collecting, storing and analyzing data for individual and aggregate members. Evaluating the effectiveness of interventions by comparing pre-established criteria prior to enrollment into the CCMP. Integrating applicable quality measures and interventions into individual care plans. Implementing educational and informational materials and programs that promulgate the quality initiatives and improvement strategies. Incorporating HEDIS measures into the overall evaluation of the CCMP activities, findings and outcomes. Data Sources and Staff Resources Quality Improvement is a data driven process. Community Health Group maintains an information data system appropriate to provide tracking of multiple data sources for implementing the QIP. These sources include, but are not limited to, the following: Encounter data Claims data QIP

35 Pharmacy data Medical records Utilization data Utilization case review data Practitioner, provider and member complaint data Practitioner, provider and member surveys results Appeals and grievance information Statistical, epidemiological and demographic member information Authorization data Enrollment data HEDIS data Behavioral Health data Risk Management data In addition, Community Heath Group s staff and analytical resources include, but are not limited to: Quality Improvement Preventive Health and Education Utilization Management Member Services Case Management Provider Relations Quality Data Analyst Information Systems Programmers Information Systems Analysts Consultant Biostatistician SPSS computer application a comprehensive system for analyzing data The Corporate Quality Improvement Committee uses the above data and resources to fully evaluate the concern by objective or quantitative methods in order to define the specific problem. The Committee must proceed to implement a problem solving action based on its findings and the objective parameters measured. After adequate time has been permitted for problem resolution, a re-evaluation is performed using the same quantitative measures. The Committee bases the re-evaluation time frame (one month, three months, six months, etc.) on the severity of the problem identified. The steps outlined below must be supported by adequate documentation of a problem-oriented approach to quality improvement (see Appendix D). Define specific indicators of performance through monitoring process. Collection and analysis of appropriate data. Identify opportunities to improve performance. Implement interventions and/or guidelines to improve performance. Measure effectiveness of interventions and/or conformance to guidelines. Re-evaluate for further potential performance improvements with the same quantitative measures. Health Information System The primary information management functions of the Information Systems Division are: Application Development and Management, Reporting, Systems Administration, Technical Support, and Database 29 QIP 2015

36 Administration. These functions are performed by Department Managers and support staff under the direction of the Informatics Manager. Application Development and Management Application development includes needs assessment, design, development, testing and implementation of customized applications where existing software applications fall short of achieving Community Health Group s business needs. A multi-disciplinary approach is taken as personnel from the Claims, Health Care Services, Member Services, Marketing, Third Party Administration (TPA), Corporate Quality, and Provider Relations Departments or Divisions may be part of the implementation team. Community Health Group s in-house programmers work with the applications analysts to design and develop the application. Subsequently, they test the customized product for data validity, security, and attainment of the application s project definition. Upon completion, end-users further test the program in everyday use. Program deficiencies, if any, are reported to the programmers who will then issue a fix. Application management includes operational support for Community Health Group s core applications, such as those purchased from third-party vendors, and customized applications. Operational support activities include application security, data processing, report generation (described below), education and training for end-users, software glitch assessments, product enhancement requests, and software upgrade testing. Reporting/Informatics Community Health Group provides exceptional service to its members, practitioners, regulatory agencies, and other customers. The Information Systems Division s internal and external customers make business decisions every day that depend on timely, valid and accurate data. Therefore, softwaredriven report generation capabilities are utilized to their fullest extent. Standard and ad hoc reports are routinely generated from the core application databases. The type of information generated includes: Longitudinal profiles of treatment or services furnished to enrollees with a specific diagnosis; Profiles of referral services ordered by each primary care practitioner; Statistical reports on the prevalence of different conditions or diagnoses among a specific group of enrollees, such as Medicare beneficiaries; and Prescription medication usage by type of enrollee, by diagnosis, or by prescribing practitioner. By virtue of being responsible for the reporting function, the Informatics Manager is responsible for the management of information systems reporting relationship between providers/sites and plan operations. Systems Administration Systems management includes the analysis of software and hardware requirements, software purchases, installation and configuration, installation of patches and enhancement updates, problem resolution, and routine maintenance. Systematic analysis ensures that all server and client software and hardware requirements can be met prior to the purchasing of any information systems products, including the need for third party software, storage capacity, memory prerequisites, central processing unit speed, operating systems, etc. If existing equipment does not meet the requirements, Community Health Group will purchase affordable yet industry-standard components that are upgradeable to allow for years of use. Systems Administration also entails the use of security to ensure that Community Health Group s information system is not breached and that data is protected. Community Health Group utilizes a QIP

37 variety of security measures including firewalls, content filtering, server and client-level anti-virus software, and encryption for the protection of business information, especially member identifiable data. Technical Support The Information Systems Division provides 24 hours a day, seven days a week technical support to both employees and contractors (e.g., contracted practitioners) of Community Health Group. Technical support activities include client and printer configurations, remote access, software support, faxing and management, network access, training, audio-visual set-ups, data security, software upgrades, and hardware upgrades and replacement. Database Administration Community Health Group obtains data from a variety of sources, including practitioners, members, the State, and vendors. As such, various data sets are required in servicing these customers, some of which may be duplicated. Instead of maintaining separate accounts of common information, such as a member s demographics, Community Health Group manages this data through the use of a Microsoft SQL Server data warehouse. The data warehouse is updated and backed up on a nightly basis to ensure users have accurate and current information at their fingertips. Through the use of integrated security, users are granted access to only the portion of the data necessary to fulfill their job functions. Medical Information System as it relates to the following subsystems: Financial; Member/ Eligibility; Provider Encounter; Claims; Quality Improvement/Utilization; and Report Generation Community Health Group utilizes a technology environment that provides sophisticated information management capabilities with Financial, Enrollee/Eligibility, Provider, Encounter/Claims, Quality Improvement Program/ Utilization, Report Generation, EDI, Security, and Web Access modules. At the same time, the system allows for Community Health Group s growth into other markets, handling of a larger claim volume, better reporting capabilities, and improved compliance with HIPAA. By implementing these technologies in conjunction with in-house customized applications, Community Health Group is ensuring that its operational and clinical staff has access to the most advanced management tools available today. Timeliness, Accuracy, and Complete Data Monitoring Community Health Group maintains extensive performance, utilization and medical cost reporting through the data warehouse. Using this data, the Claims Department routinely monitors timeliness and quality through the use of audit and productivity reports. Information that is routinely analyzed includes the following: Daily Claims Analyst productivity reports Institutional claims that do not have a whole claim price line Claims with received dates that are prior to dates of service Denied claims with a dollar value greater than zero Disputed claims Unposted claims that will get paid Claims posted beyond 60 calendar days Aging reports (i.e., claims on hand broken down by time period - <30 days, days, days, > 90 days) Pended claims report 31 QIP 2015

38 Reporting Subsystem Community Health Group s reporting subsystem consists of extensive production reporting catalogs and flexible, ad hoc report creation tools. The Information Systems Division is responsible for the coordination, development, and production of these reports. Reports are generated from three major sources claims, membership, and medial management. Most operational reports are generated from these sources. All other utilization, quality and decision support reports are generated from the data warehouse. These reports include HEDIS, provider profiling, and other statistical and quality measures. Data Warehouse Reporting The data warehouse stores key member, provider, utilization, case, quality, outcome, encounter, pharmacy and claims data in a common format in a single location. The warehouse enhances this raw data by automatically creating views and objects to summarize the data into key reporting. The types of reports include: Population Information - Data on enrollee characteristics relevant to health risks or utilization of clinical and non-clinical services, including age, sex, race, ethnicity, language, and disability or functional status. Performance Measures - Data on the organization s performance as reflected in standardized measures, to be compared when possible to: Local, State, or national information on performance of comparable organizations. Other Utilization, Diagnostic, and Outcome Information - Data on utilization of services, procedures, medications and devices; inpatient and ambulatory diagnoses; adverse incidents (such as deaths, avoidable admissions, or readmissions); and patterns of referrals or authorization requests. External Data Sources Data from outside organizations, including Medicare or Medicaid managed care data, data from other managed care organizations, and local or national public health reports on conditions or risks for specified populations is collected for comparison and benchmarking. Enrollee Information on Their Experiences with Care Data from surveys (such as the Consumer Assessment of Healthcare Providers & Systems - CAHPS), information from the grievance and appeals processes, and information on disenrollments and requests to change providers is used to monitor members experiences with care and services. (Note that general population surveys may under-represent populations who may have special needs, such as linguistic minorities or the disabled. Assessment of satisfaction for these groups may require over sampling or other methods, such as focus groups or enrollee interviews.) In addition to information generated within the organization, information supplied by purchasers, such as data on complaints shall be assessed. Quality Improvement Program Activities The QI Program s scope includes implementation of QI activities or initiatives. The QI Committee and the subcommittees select the activities that are designed to improve performance on selected high volume and/or high-risk aspects of clinical care and member service. QIP

39 Prioritization Certain aspects of clinical care and service data may identify opportunities to maximize the use of quality improvement resources. Priority will be given the following: The annual analysis of member demographic and epidemiological data Those aspects of care which occur most frequently or affect large numbers of members Those diagnoses in which members are at risk for serious consequences or deprivation of substantial benefit if care does not meet community standards or is not medically indicated Those processes involved in the delivery of care or service that, through process improvement interventions, could achieve a higher level of performance Use of Committee Findings To the degree possible, quality improvement systems are structured to recognize care for favorable outcomes as well as correcting instances of deficient practice. The vast majority of practicing physicians provides care resulting in favorable outcomes. Quality improvement systems explore methods to identify and recognize those treatment methodologies or protocols that consistently contribute to improved health outcomes. Information of such results is communicated to the Board of Directors and providers on a regular basis. Written communication to primary practitioners is the responsibility of the Committee chairperson. Submission of written corrective action plans, as necessary, is required for the Committee's approval. Significant findings of quality improvement activities are incorporated into practitioner educational programs, the re-credentialing process, and the re-contracting process and personnel annual performance evaluations. All quality improvement activities are documented and the result of actions taken recorded to demonstrate the program's overall impact on improving health care and the delivery system. Clinical Practice Guidelines Community Health Group utilizes evidence-based practice guidelines to establish requirements and measure performance on a minimum of three practice guidelines (acute, chronic and behavioral health) annually to strive to reduce variability in clinical processes. Practice guidelines are developed with representation from the network practitioners. The guidelines are implemented after input from participating practitioners of the Clinical Quality Improvement, Utilization Management and Pharmacy and Therapeutics Committees. Guidelines will be reviewed and revised, as applicable, at least every two years. Preventive Health/HEDIS Measures The Clinical Quality Improvement Committee will determine aspects of care to be evaluated based on member population and regulatory requirements. At a minimum, HEDIS performance indicators will be monitored annually based on product type, i.e. Medi-Cal or Medicare. These include: Adult Body Mass Index (BMI) Assessment 1,2 Annual Monitoring for Patients on Persistent Medications 1 Antidepressant Medication Management Appropriate Testing for Children with Pharyngitis 1 Appropriate Treatment for Children with Upper Respiratory Infection 1 Avoidance of Antibiotic Treatment for Adults with Acute Bronchitis 1 Breast Cancer Screening 1 Care for Older Adults 1 Cervical Cancer Screening 1 Childhood Immunizations Status 1 33 QIP 2015

40 Children and Adolescent s Access to Primary Care Providers 1 Chlamydia Screening in Women 1 Cholesterol Management After Cardiovascular Events (Screening rate only) 1,2 Colorectal Cancer Screening 2 Comprehensive Diabetes Care 1,2 Controlling High Blood Pressure 1,2 Follow-Up After Hospitalization for Mental Illness 2 Flu Shots for Older Adults 2 Glaucoma Screening in Older Adults 2 Identification of Alcohol and Other Drug Services 2 Medication Reconciliation Post-Discharge 2 Medical Assistance with Smoking Cessation (Advising Smokers to Quit) Osteoporosis Management in Women Who Had a Fracture 2 Pharmacotherapy Management of COPD Exacerbation 1, 2 Persistence of Beta Blocker Treatment After a Heart Attack 1,2 Pneumonia Vaccination Status for Older Adults 2 Potentially Harmful Drug-Disease Interactions in the Elderly 2 Prenatal and Postpartum Care: Timeliness of Prenatal Care 1 Prenatal and Postpartum Care: Postpartum Care 1 Use of Appropriate Mediations for People with Asthma 1 Use of Imaging Studies for Low Back Pain 1 Use of Services Ambulatory Care Use of Services Inpatient Utilization Use of Services Outpatient Drug Utilization 2 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 1 Weight Assessment/Counseling for Nutrition & Physical Activity for Children/Adolescents 1 Well Child Visit in the Third, Fourth, Fifth, and Sixth Years of Life 1 1 Medi-Cal Members Only 2 Medicare Members Only Disease Management Programs The health care services staff, Clinical Quality Improvement Committee and network practitioners identify members with, or at risk for, chronic medical conditions. The Clinical Quality Improvement Committee is responsible for the development and implementation of disease management programs for identified conditions. Disease management programs are designed to support the practitionerpatient relationship and plan of care. The programs will emphasize the prevention of exacerbation and complications using evidence-based practice guidelines. The active disease management programs and their components will be identified in the annual QI work plan. Complex case management and chronic care improvement are major components of the disease management program. Specific criteria are used to identify members appropriate for each component. Member self-referral and practitioner referral will be considered for entry into these programs. Following confidentiality standards, eligible members are notified that they are enrolled in these programs, how they qualified, and how to opt-out if they desire. Case managers and care coordinators are assigned to specific members or groups of members and defined by stratification of the complexity of their condition and care required. The case managers/care coordinators help members navigate the care system and obtain necessary services in the most optimal setting. QIP

41 Components of complex case management and chronic care improvement programs shall include: Members' right to decline participation or disenroll from case management programs and services Initial assessment of members' health status, including condition-specific issues Documentation of clinical history, including medications Initial assessment of activities of daily living Initial assessment of mental health status, including cognitive functioning Initial assessment of life planning activities Evaluation of cultural and linguistic needs, preferences or limitations Evaluation of caregiver resources Evaluation of available benefits Development of a case management plan, including long- and short-term goals Identification of barriers to meeting goals or complying with the plan Development of a schedule for follow-up and communication with the member Development and communication of self management plans for members Process to assess progress against the case management plans for members Continuity and Coordination of Care The continuity and coordination of care that members receive is monitored across all practice and provider sites. As meaningful clinical issues relevant to the membership are identified, they will be addressed in the quality improvement work plan. The following areas are reviewed for potential clinical continuity and coordination of care concerns. Primary care services OB/GYN services Behavioral health care services Inpatient hospitalization services Home health services Skilled nursing facility services The continuity and coordination of care received by members includes medical care in combination with behavioral health care. Community Health Group collaborates with behavioral health practitioners to ensure the following activities are accomplished: Information Exchange Information exchange between medical practitioners and behavioral health practitioners must be member-approved and be conducted in an effective, timely, and confidential manner. Referral of Behavioral Health Disorders Primary care practitioners are encouraged to make timely referral for treatment of behavioral health disorders commonly seen in their practices, i.e., depression. Evaluation of Psychopharmacological Medication Drug use evaluations are conducted to increase appropriate use, or decrease inappropriate use, and to reduce the incidence of adverse drug reactions. Data Collection Data is collected and analyzed to identify opportunities for improvement and collaborate with behavioral health practitioners for possible improvement actions. Implementations of Corrective Action Collaborative interventions are implemented when opportunities for improvement are identified. 35 QIP 2015

42 Risk Management The purpose of the Risk Management component of the QI Program is to prevent or reduce risk due to adverse member occurrences associated with care or service. The risk management function involves identifying potential areas of risk, analyzing the cause and designing interventions to prevent or reduce risk. The activities of Quality Improvement, Utilization Management, Member Services, Provider Relations and Risk Management are coordinated. Member Satisfaction, Complaint, and Grievance/Appeal Monitoring An NCQA certified vendor conducts a member satisfaction survey (Consumer Assessment of Healthcare Providers and Systems CAHPS) annually by all product lines. The Health Outcomes Survey (HOS) for the Medicare line of business will be added for Medicare Advantage Special Needs Plan (SNP) members. A behavioral health satisfaction survey is also conducted for those members who receive behavioral health care through contracted vendors. The results of the surveys are reported to the Service QIC, Public Policy Committee, CorpQIC and Board of Directors. Additionally the behavioral health satisfaction results are reported to the Behavioral Health Advisory Committee. Quarterly summaries of complaints and grievances/appeals are reported to the Service QIC and Public Policy Committee. Reporting is trended by type of complaint, Community Health Group departments, sites, facilities and physicians as indicated. Cases reviewed by the Chief Medical Officer are included in the quarterly summaries. Any complaint that has a potential quality of care issue receives medical review as follows: The QI Specialist screens it immediately upon receipt for potential quality issues. As indicated, within four days of receipt, supporting documentation is requested from primary care sites, hospitals, etc. The Chief Medical Officer reviews the complaint and any supporting documentation, categorizes the quality of care concerns, communicates with primary care provider as indicated and provides an acknowledgement letter to the member within 30 days of receiving a medical quality of care grievance. A written summary, as well as a report of action is taken in response to the quality of care grievance, which is forwarded to the CorpQIC, the Board, and to the member who initiated the complaint. Practitioner Compliance Monitoring Community Health Group monitors and evaluates practitioners' compliance with policies and procedures through on-site provider compliance surveys. The purpose of this monitoring is to ensure compliance with established protocols and policies and assist in the implementation of corrective action plans, as indicated. During each compliance survey, a site facility inspection is conducted and a review of medical records per physician per age group (adults/pediatrics) for members being treated is performed. The medical record score is based on a survey standard of ten randomly selected records per provider. All ten records surveyed are from adult, obstetric or pediatric preventive care areas. For sites with only adult, only obstetric, or only pediatric members, all ten records surveyed are only in that preventive care area. QIP

43 The site s contact person is provided with an exit summary at the end of the inspection and copies of the completed survey tools. The formal summary report is presented to the Corporate Quality Improvement Committee for review and recommendations and then sent to the Chief Medical Officer of the site surveyed with copies to the site administrator and/or contact person. A corrective action plan is required for deficiencies noted and a follow-up survey is conducted for compliance ratings of Conditional Pass and Not Pass. The follow-up visit is scheduled from the time the formal summary report is provided to the site. Site and Medical Records (Adults, Pediatrics, & Obstetrics) Review Compliance Ratings Compliance ratings standards are determined by the California Department of Health Care Services. Facility Exempted Pass: 90% or above, without deficiencies in critical elements or deficiencies in infection control or pharmacy No Corrective Action Plan (CAP) required. Conditional Pass: 80-89%, or 90% or above with deficiencies in critical elements CAP required Not Pass: Below 80% - CAP required. Medical Records Exempted Pass: 90% or above No Corrective Action Plan (CAP) required. Conditional Pass: 80-89% CAP required. Not Pass: Below 80% - CAP required. Practitioner Credentialing Process Introduction Community Health Group (CHG) promotes quality care and access for members by maintaining a panel of participating practitioners and providers who meet CHG s eligibility requirements. All applicants undergo a comprehensive review of their qualifications including education and training, licensure status, board certification, hospital privileges, and malpractice history in accordance with NCQA, state and federal regulatory standards. This program description provides an overview of credentialing & recredentialing policies, requirements and process including delegation. Purpose The primary objective of the credentialing process is to facilitate the selection of health care practitioners/providers who are chosen for participation based upon a number of factors such as compliance with CHG s credentialing standards, geographic area, specialty and network needs. Objectives To ensure access, availability, and quality care to our members. To ensure that practitioners meet CHG s established criteria. To ensure the credentials of all applicants are in accordance with CHG s established policies and procedures and based upon NCQA and regulatory standards through primary source verification. To ensure that practitioners continue to meet CHG s high standards by the ongoing monitoring of member complaints and sanctions and information from quality improvement activities. To ensure that all practitioners/providers are recredentialed every three years. 37 QIP 2015

44 CHG s credentialing program applies to all physicians and other licensed independent practitioners including but not limited to MDs, DOs, chiropractors, nurse midwives, nurse practitioners, oralmaxillofacial surgeons, podiatrists, psychiatrists*, psychologists *, social workers *, and therapists*. *Includes all behavioral health practitioners who are certified or registered by the state to practice independently. The credentialing program also applies to hospitals, skilled nursing facilities, home health agencies, ambulatory surgical centers, and behavioral health facilities. Authority/Responsibility Credentialing Department The Credentialing Department has responsibility of the collection of all the required documentation, reviewing the application for completeness, performing primary source verification, querying the appropriate entities and the completion of the practitioner files in preparation for review by the Chief Medical Officer or the Credentialing Sub-Committee. The Credentialing Services Manager is responsible for the day-to-day operations of the Credentialing Program. Chief Medical Officer CHG s Board of Directors has delegated to the Chief Medical Officer the responsibility of annually reviewing the Credentialing Program, and to update as needed; and to ensure that the terms of the Credentialing Program are executed. Credentialing Sub-Committee CHG s Credentialing Sub-Committee functions as the CHG Credentialing Committee for applicants who do not meet credentialing standards. Meeting every month, the committee is comprised of (6) practitioner members with CHG s Chief Medical Officer serving as the Chairperson. The range of specialties represented includes Family Practice (2), Internal Medicine (1), Pediatrics (1), Obstetrics- Gynecology (1) and Nurse Practitioner (1). The following CHG staff members also participate on the Credentialing Sub-Committee - the Director, Corporate Quality and the Credentialing Services Manager. The committee also functions as the peer-review committee for regulatory actions and quality of care issues. Provider File The Contracting Department is responsible for the management and maintenance of practitioner data in the network Provider Module. Upon notification of acceptance from Credentialing, the Contracting Department sets up new practitioners in the Diamond system including hospital based physicians, midlevel practitioners, ancillary practitioners and facilities. The Contracting Department processes changes to existing in-plan practitioner data and practitioner terminations upon notification from Provider Relations. The Contracting & Credentialing Departments also perform data analysis and troubleshooting on a proactive ad hoc basis to ensure the integrity of practitioner information between both systems. Confidentiality All credentialing information obtained during the credentialing/recredentialing process is handled in a manner that protects the confidentiality of the applicant and may not be disclosed except as permitted by applicable law. Credentialing information is kept in a secure database and access to such information is limited through systems security features and is available only to staff with a need to know. All practitioner files are stored in a locked fireproof cabinet while in process, and only designated staff members have access to the files. Provider files are scanned and kept electronically. All QIP

45 credentialing/recredentialing information distributed at the Credentialing Sub-Committee meetings is collected at the conclusion of the meeting and disposed of by placing in locked shredding bins. Minutes of each Credentialing Sub-Committee meeting are maintained in a confidential and secure manner. Annual Review The Credentialing Program and the effectiveness of the program is reviewed, evaluated, and revised, if applicable, at least annually by the Chief Medical Officer and the Credentialing Services Manager. Data Integrity On a monthly basis, the Credentialing and Contracting departments perform a data comparison to ensure that the integrity of the practitioner data presented in the directories and other member materials is consistent with the credentialing data including education, training, board certification and specialty. On a daily basis, all practitioner data changes are reviewed and verified for accuracy. Credentialing Criteria All Practitioners Each applicant must complete an application form which includes: A signed release/authorization which grants CHG the ability to verify key information. At the time of the credentialing decision, the signature date must not be more than 365 days old. Otherwise, CHG will require the applicant to refresh the application prior to presenting for review. An attestation by the applicant of the correctness and completeness of the application. The application includes a current and signed attestation that addresses: Reasons for any inability to perform the essential functions of the position, with or without reasonable accommodation Lack of present illegal drug use History of loss of license or certifications History of felony convictions History of loss or limitations of privileges or disciplinary actions Current malpractice insurance coverage An application other than CHG s may be used if it provides all the demographic and practice information required for CHG s credentialing requirements, or if it is a state-mandated application. Physicians All physician applicants must demonstrate that they meet the participation/continued participation criteria listed below: Current, valid, unrestricted license(s) to practice medicine or osteopathy. Current, valid, unrestricted Federal DEA certificate, if applicable. Medical school/dental school graduation. Completion of appropriate residency and/or fellowship training programs in the specialty for which applicant is applying. Board Certification - CHG requires all physicians have formal training and obtain certification by the American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) in all specialties under which they practice and wish to be listed in the CHG Practitioner Directory. Subspecialty certification and/or certificates of added qualifications from the ABMS are required in order for CHG to recognize and list a physician in that specialty in its practitioner directory. CHG may waive board certification requirements at its sole discretion, for compelling network needs or other business reasons, provided that the physician meets all other requirements. 39 QIP 2015

46 Detailed account of professional work history for the past five (5) years, with no unexplained gaps of more than six (6) months. Verbal clarification for gaps exceeding six (6) months will be accepted. Written clarification is required for gaps greater than one (1) year. Unrestricted clinical privileges at a CHG-participating hospital, or written documentation from the applicant outlining an admitting arrangement by which CHG members are referred for admission to a CHG-participating facility. Documentation of current malpractice insurance coverage. Physicians are required to carry a minimum of $1,000,000/$3,000,000. Professional liability claims history during the past five (5) years. Absence of sanctions, restrictions, and/or limitations in scope of practice by any state licensing board or regulatory agency. Absence of Medicare/Medicaid sanctions. Non-Physicians All other practitioner applicants must demonstrate that they meet the participation/continued participation criteria listed below: Current, valid, unrestricted license(s) to practice in his/her specialty; Current, valid, unrestricted Federal DEA certificate, if applicable; Completion of appropriate education and training in his/her specialty; Confirmation of Board Certification/certification, if applicable; Detailed account of professional work history for the past five (5) years, with no unexplained gaps of more than six (6) months; Unrestricted clinical privileges at a CHG participating hospital, if applicable; Documentation of current malpractice insurance coverage; Professional liability claims history during the past five (5) years; Absence of sanctions, restrictions, and/or limitations in scope of practice by any state licensing board or regulatory agency; Absence of Medicare/Medicaid sanctions. Organizational Providers CHG conducts a quality assessment for the following types of health care organizations before contracting with and at least 3 years thereafter: Ambulatory Surgery Centers - Free Standing Office Based Surgery Centers Home Health Agencies Hospitals Skilled Nursing Facilities Behavioral Health Care Facilities (ambulatory, inpatient and residential) CHG confirms that the organization is in good standing with state and federal bodies, is licensed in the state as required, has been reviewed and approved by an accrediting body. Acceptable accreditation and certification entities: Joint Commission for Accreditation of Health Care Organizations (JCAHO) Community Health Accreditation Program, INC (CHAP) Accreditation Association for Ambulatory Health Care (AAAHC) The Rehabilitation Accreditation Commission (CARF) Continuing Care Accreditation Commission (CCAC) QIP

47 The Commission on Accreditation of Birth Centers American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) If the organization is not accredited, a site visit is required. A state or federal (DHCS, CMS) review may be substituted for a site visit. On a triennial basis, CHG will reassess facilities for continued participation in the network by confirming that it continues to be in good standing with state and federal regulatory bodies and the appropriate accrediting body. Non-Discrimination CHG s credentialing process does not discriminate in the selection or termination of practitioners on the basis of sex, age, national origin, race, religion, color, marital status, or sexual preference or orientation. CHG does not discriminate in the selection or termination of practitioners who serve high-risk populations or who specialize in the treatment of costly conditions. In order to assure nondiscrimination, CHG annually reviews denied applications and reviews what the decisions were based on. Application Review Upon receipt of the application and any supporting documentation, the Credentialing Specialist will review the application timeliness and completeness. The signature date should not be older than sixty (60) days in order to begin the credentialing process. If the application is complete, the documentation received will be date stamped and data will be entered into the Credentialing Database. If not, the Credentialing Specialist will contact the applicant or IPA/PHO representative via telephone or fax with a request for missing items. Once it has been established than an application is complete, the Credentialing Specialist will initiate processing and conduct primary source verification. Primary Source Verification Primary source verifications are conducted on all applicants. Verifications must be completed within 180 days from the date of the decision. Licensure via appropriate state agency or the Internet DEA via the NTIS database or certificate copy Board Certification via ABMS publications, Certifacts, or appropriate specialty board Medical School/Dental School Graduation & Residency verified per licensure in CHG service areas according to documented policies of the respective state licensing boards Fellowship via educational primary source Clinical Privileges via primary source Malpractice Insurance Coverage via primary source Professional Liability Claims History/Disciplinary Activity query of the National Practitioner Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB) or primary source Sanctions/Limitations on Licensure within the past five years information will be obtained from applicable state regulatory agency Sanctions/Limitations on Licensure outside the CHG service area query of the Federation of State Medical Boards (FSMB) on physician applicants at the time of credentialing or applicable state regulatory agency Medicare/Medicaid Sanctions query the National Practitioner Data Bank (NPDB) or Cumulative Sanctions Report Work History - professional work history for the past five (5) years, with no unexplained gaps of more than six (6) months. Gaps exceeding six (6) months must be reviewed and clarified either verbally or in writing. Written clarification is required for gaps greater than one (1) year. 41 QIP 2015

48 File Preparation Upon completion of primary source verification, queries, and site visit, if applicable, the file is prepared for review. The file will include: Completed credentialing application and checklist Primary source verification of all elements Work history NPDB/FSMB query result Sanction activity summary, if applicable Site visit results Any other relevant data Decision-Making Process The Chief Medical Officer has determined that all files, credentialing and recredentialing, that meet CHG's established criteria are considered to be "clean. A roster of applicants that meet all of CHG s criteria will be forwarded weekly to the Chief Medical Officer for his review and sign-off that they are complete, clean, and approved for acceptance or continued participation. The Credentialing Sub-Committee reviews the credentials of all physicians and licensed independent practitioners being credentialed or recredentialed who do not meet the organization s established criteria, and makes recommendations regarding credentialing decisions which the organization considers. The confidential minutes of each meeting are recorded and reflect the recommendations/advice of the Committee and any relevant discussion pertaining to the recommendations. The date of the Chief Medical Officer sign-off or the Committee meeting is considered the effective date. Notification All applicants are notified in writing within sixty (60) calendar days of the decision to accept or deny their application unless states mandate otherwise. If accepted, the file is forwarded to Provider Relations for entry into Diamond, then to Network Operations for contract execution and the sending of the welcome packet. The date of the Chief Medical Officer sign-off or the QIC meeting is the effective date. If denied, the practitioner is sent a denial letter explaining the reason(s) for the denial. Applicant Rights CHG has policies and procedures in place that define: The right to review information submitted to support his/her credentialing application unless the disclosure of certain information or the source of information is prohibited by law, contract or agreement with the entity that provided the information to CHG, and the right to correct erroneous information submitted by another party for use in the credentialing process. The process for notification to a practitioner of a discrepancy in the information obtained during the credentialing process that varies substantially from the information provided to CHG by the applicant. Notification to the applicant will be made in writing within ten (10) working days of the receipt of such discrepancies. The applicant shall have ten (10) working days after receipt of notification to submit an explanation of such discrepancies in writing to the Credentialing Department. The applicant will be notified in writing within ten (10) working days that his/her QIP

49 explanation has been received and will be taken into consideration while completing the application process. Discrepancies will be reviewed at the next regularly scheduled QIC meeting. The right to be informed of the status of his/her credentialing or recredentialing application upon request. The applicant may contact the Credentialing Department to request information on the status of his/her credentialing/recredentialing application. Practitioners are informed of their rights on the practitioner application and in the Provider Manual. Delegation CHG may delegate specific credentialing functions, including primary source verification and/or decision making, to an IPA/PHO or other professional healthcare organization by formal written agreement, providing the delegate agrees to adhere to CHG s credentialing criteria. The agreement outlines the responsibilities of CHG and the delegate, the process by which CHG will evaluate the delegate s performance, frequency of reporting requirements (at least semi-annually), and how CHG will proceed if the delegate does not fulfill its obligations. CHG will evaluate the delegate s performance prior to delegation following NCQA standards and will include a review of practitioner files as well as a review of the related delegate policies and procedures. Once the delegation agreement is executed, CHG will perform oversight, including file review, policy review and report evaluation at least annually thereafter. Any identified opportunities for improvement will be addressed with the delegate and closely monitored thereafter. CHG retains the right to approve, suspend, deny or terminate practitioners and/or providers participating in the network. None of CHG s delegated credentialing arrangements include the use of any member protected health information. Site Review Initial Credentialing Visit CHG requires a site visit for all primary care practitioners, obstetricians/ gynecologists, and high volume behavioral health care practitioners prior to the initial credentialing decision. The site visit includes a structured review of the facility and of medical record-keeping practices. The site visit component includes an assessment of: Physical accessibility and appearance Adequacy of waiting room and examining room space Appointment availability Adequacy of medical record keeping practices Maintenance of patient confidentiality Patient safety practices New applicants joining existing practices with a passing site visit on file may be credentialed based on the existing site visit score. Any primary care practitioner or obstetrician/gynecologist who adds a site or moves to a new location will receive an on-site visit at the time of CHG notification. Scoring Standards An initial passing score of 80% is required. Scores for the Medi-Cal line of business are rated according to the California Department of Health Services Policy Letter as: 43 QIP 2015

50 Facility Exempted Pass: Quality Improvement Program Description 90% or above, without deficiencies in critical elements or deficiencies in infection control or pharmacy No Corrective Action Plan (CAP) required. Conditional Pass: 80-89%, or 90% or above with deficiencies in critical elements CAP required. Not Pass: Below 80% - CAP required. Medical Records Exempted Pass: 90% or above No Corrective Action Plan (CAP) required. Conditional Pass: 80-89% CAP required. Not Pass: Below 80% - CAP required. Subsequent Reviews A failing score, multiple key element failures or quality of care issues will require a corrective action plan and a reevaluation every six months until the deficiencies are corrected. Community Health Group has an ongoing process to gather information regarding the facilities of participating practitioners after the initial site visit. Additional information regarding the facilities may be received from patient complaints, practitioner representative visits or case management. If any adverse information is received, a site visit will be scheduled at the site in question. This process is monitored every 6 months or on-going. A score of 80% is required on any subsequent reviews. Recredentialing CHG practitioners and providers are recredentialed, at a minimum, within thirty-six (36) months of the previous credentialing/recredentialing decision. At recredentialing, CHG verifies whether there has been any sanction activity that might impact a practitioner s ability to provide safe and appropriate care through review of state sanctions, restrictions on licensure and/or limitation of scope of practice and query of the Office of Inspector General s web site. Practitioners and providers must complete a recredentialing application that includes a current, signed and dated attestation that addresses: Reasons for any inability to perform the essential functions of the practitioner with or without accommodation; Lack of present illegal drug use; History of loss or limitation of privileges or disciplinary activity; Current malpractice insurance coverage; and Correctness and completeness of the application. Primary source verifications are conducted on all applicants. Verifications must be completed within 180 days from the date of the decision. CHG will collect and/or primary source verify the following recredentialing elements for participating physicians and other practitioners via the sources identified above. Current, valid, unrestricted license(s) Current, valid, unrestricted Federal DEA certificate, if applicable Board Certification History of liability claims history Sanctions and restrictions and/or limitations Medicare/Medicaid sanctions Current malpractice coverage in the amount of $1 million per occurrence/$3 million aggregate for physicians and other practitioners Clinical privileges at a CHG affiliated hospital QIP

51 No later than 365 days following the date of the signed attestation, all files that meet CHG's standards are forwarded to the Chief Medical Officer for review and approval. Recredentialing candidates who do not meet CHG's standards are forwarded to the Quality Improvement Committee for review and recommendation of continued participation. Practitioners and providers who do not submit recredentialing information will result in termination from CHG s participating practitioner panel. Ongoing Monitoring To ensure quality and safety of care between credentialing cycles, CHG performs ongoing monitoring for practitioner complaints, sanctions or limitations on licensure, Medicare/Medicaid sanctions and adverse events and will implement appropriate interventions if instances of poor quality are identified. Practitioner specific complaints are investigated immediately and include an evaluation of the specific complaint and the practitioner's history of issues, if applicable. The complaint will be tracked and trended, and appropriate action taken when occurrences of poor quality are identified. CHG has an ongoing process to gather information regarding the facilities of participating practitioners after the initial site visit, and if adverse information is received, a visit will be scheduled at the site in question. CHG will review reports from state agencies regarding practitioners who have received sanctions or limitations on licensure and Medicare/Medicaid sanction reports within 30 calendar days of release. If a participating practitioner is identified on a sanction report, or there is evidence of poor quality, the practitioner's ability to provide services will be reviewed by the Chief Medical Officer. The Chief Medical Officer s recommendation will be presented to the QIC who will review and make subsequent recommendations. If a participating practitioner is identified on the Medicare/Medicaid sanction report, termination proceedings will be initiated. Newspaper articles will be investigated and brought to the Chief Medical Officer and Provider Relations Department for review. The Chief Medical Officer s recommendation will be presented to the Credentialing Sub-Committee who will review and make subsequent recommendations. The Chief Medical Officer reserves the right to suspend, or terminate a practitioner prior to review by Credentialing Sub-Committee, based on quality issues if necessary. Terminations CHG may terminate, suspend, restrict or limit a practitioner s or provider s participating status with CHG by providing written notice to the practitioner/provider and in accordance with the applicable practitioner/provider contract for the following reasons: Practitioner/provider no longer complies with the CHG eligibility requirements and/or selection criteria; Practitioner s arrest, conviction, indictment or charge with any felony charge related to moral turpitude or the practice of medicine; CHG determines that practitioner has provided false and/or misleading information relating to billing, services rendered, and/or credentialing or recredentialing; CHG determines that the quality of care/quality of service may result in danger to the health and safety of CHG s members; Practitioner s/provider's liability insurance as required by CHG is terminated, canceled or materially decreased; 45 QIP 2015

52 Practitioner s/provider s license to practice medicine has been restricted, suspended, revoked, or reduced in the state(s) where CHG s members may receive services from such provider/practitioner; Practitioner/provider has been suspended or excluded from the Medicare/Medicaid program or any other federal or state health care program. If a practitioner or provider is suspended or terminated, the affected physician will receive written notice of the reasons for the action including, if relevant, the standards used to make the decision. The physician will be given written notice of his/her right to a hearing and the process and timing for requiring a hearing. Practitioners and providers have the right to appeal CHG s decision to take adverse action against their participation status for quality-related reasons and in accordance with the Health Care Quality Improvement Act of Prior to the hearing, CHG has the option to initiate a range of actions depending on the nature of the circumstances. These could include but are not limited to: Educational interventions Limitation of privileges Closure of practice to CHG members Sanctioning by the committee Requiring a corrective action plan with regular monitoring In accordance with the requirements of federal and state law, CHG shall notify any appropriate regulatory authority, including the National Practitioner Data Bank (NPDB), of any final decision of the Credentialing Sub-Committee to take adverse action regarding a provider s/practitioner s participation for quality-related reasons. In reporting, CHG shall report the name of the provider/practitioner; a description of acts/omissions or other reasons for the adverse action. The written appeal process including the right to a fair hearing is communicated to the practitioners in the practitioner manual and in the contract. Practitioner Peer Review Process The primary purposes of the peer review process are to: Monitor the individual clinical performance of providers. Review the effectiveness and appropriateness of modalities and procedures. Examine member grievances and satisfaction reports to determine necessity or corrective action. Review the quality, content and completeness of medical records to include an evaluation of legibility and problem-oriented progress notes (concurrently and retrospectively). Review the appropriate use of the formulary and documentation of instructions to Members. Make recommendations to the Quality Improvement Committee chairman regarding provider outcomes of care. Initial remedial actions must be submitted as a formal recommendation to the Corporate Quality Improvement Committee Chair and may be in the form of in-service education. Organization Physician practitioners (with non-physician medical providers participation, when indicated) conduct peer view. The suggested format for peer review evaluation is attached. The physicians at each primary care site are responsible for supervising non-physician medical QIP

53 practitioners. Letters documenting this relationship are kept on file at each primary care site and Medical Group office and at Community Health Group. The minutes of the Peer Review sessions are kept confidential in the Quality Improvement process. Quality of care concerns identified via the Quality Improvement process are categorized for assessment, intervention, and resolution as follows: Level 0 - No quality of care issue. Level 1 - Pertains primarily to the art of caring and communication issues. Level 1a - Surgical complications - Untoward surgical or post surgical events, which are not determined to be due to negligence or poor technical ability. Level 1b - Pertains to minor systems problems including documentation issues. Level 2a - Pertains to systems problems with potential for adverse outcome to member or cases, which demonstrate adverse effect on the member. Level 2b - Pertains primarily to clinical issues and/or clinical judgment directly impacting member's care with the potential for mild to moderate adverse effect on the member or for cases, which demonstrate mild adverse effect on the member. Level 2c - Clinical issues which reflect the potential for significant to serious adverse effect on the member or for those cases which demonstrate moderate adverse effect on the member. Level 3 - Medical mismanagement with significant adverse effect on the member. "Significant Adverse Effect" is defined as: 1) Unnecessarily prolonged treatment, complications, or readmission; or 2) Health care management that results in anatomical or physiological impairment, disability or death. Once the significance of the identified quality issue is determined, the Credentialing Sub-Committee members select the appropriate corrective action. Corrective action plans are categorized by the choices listed below. This breakdown allows a method for tracking the different types of corrective action interventions that are implemented, and provides a standardized method for determining the most appropriate course of action to take. Notification Education Intensification Coordination with licensing and accreditation bodies Sanction plan Other interventions Improvement Strategies Notification The provider and/or other party involved in the quality issue are notified when the CorpQIC develops a corrective action plan. Written notification includes a description of the problem, the corrective action process to be initiated, and a time frame in which to implement and/or complete the corrective action. An explanation on how to appeal the Committee's decision or submit further explanatory information is included in the notification letter that is sent to the provider and/or other involved parties. Education Educational methods are used as a corrective action when it appears that an educational deficit may be causing the identified problem. Educational corrective actions may include: Telephone and/or one-on-one discussion with the responsible parties 47 QIP 2015

54 Letters or notices defining case specifics and the appropriate action plan Suggested clinical literature reading Self-education courses Continuing clinical education course recommendation Monitoring by another physician Intensification/Focused Review Intensification includes focused review of all care or cases involving the particular provider in question, for a limited period of time. The provider is then re-evaluated by the CorpQIC, based on the findings of the cases reviewed since the initial problem was first identified. The purpose is to determine if the issue in question was an isolated event or follows a pattern or trend. Coordination with Licensing and Accreditation Bodies Information regarding significant adverse outcomes determined to be the fault of a contracted provider is coordinated with regulatory agencies such as the National Practitioner Data Bank and the California Medical Board. The types of cases that would be reported must demonstrate severe, persistent patterns of inappropriate practice after the provider in question: has been provided the opportunity to present his/her views on the matter to the CorpQIC, failed to break the pattern after corrective action has been repeatedly requested, and has exhausted his/her appeal rights. Sanction Plan The CorpQIC and/or Board may recommend sanctions for cases where a practitioner fails to alter a behavior after repeated reminders. However, these sanctions do not always result from identification of adverse outcomes. For example, cases where a physician is repeatedly not following Community Health Group s guidelines for obtaining prior authorization for a referral to a specialist may also fall into this category. The quality of care may not be affected in this instance, but the provider is considered to be consistently non-compliant with guidelines. A letter from the Board warning the provider of possible dismissal from the provider network if cooperation is not obtained may be a sanction used in this particular situation. If a more severe sanction is recommended by the CorpQIC, such as actual dismissal from the plan, and reporting to the National Practitioner Data Bank is indicated, the Board is immediately notified of the specifics and requested to provide recommendations and make the final decision to terminate a contract with a practitioner. Other Interventions Based on the uniqueness of each situation, interventions for corrective action may be indicated that do not necessarily appear in the guidelines. For these situations, the CorpQIC members, under the direction of the Chief Medical Officer, may determine the most appropriate corrective action to formulate. Corrective Action Requirements Regardless of the type of corrective action selected for use by the CorpQIC, certain parameters are followed for developing the implementation plan. These are as follows: QIP

55 Date the corrective action is to begin, how long it will be in effect, and when it will be re-evaluated are clearly defined. Responsible parties for ensuring implementation and monitoring of the corrective action plan are identified. Anticipated outcome is identified. Objective goals must be incorporated into the plan to provide effective measurement tools. Re-evaluation of the identified quality problem is included in the plan to determine its success. Subsequent action plans are developed and initiated using the same parameters as the first. Member Health Education Community Health Group makes materials available to providers to educate members on the health risk behaviors and refers members to additional resources and programs. The materials include member tip sheets corresponding to each age-specific assessment; talking points for the provider to initiate discussions of risks identified, and brief counseling points for the provider. Community Health Group has several processes in place to remind members, and provide education and outreach, about the importance of receiving recommended preventive care services. Delegation Community Health Group may delegate those Utilization Management, Credentialing, Medical Record and Facility Review, and Claims activities to IPA/medical groups and/or vendors who meet the requirements as defined in a written delegation agreement and delegation policies. Community Health Group does not delegate Quality Improvement, Members Rights and Responsibilities (this includes Member Appeals), New Technology Assessment or Preventive Health activities. Community Health Group believes in a partnership relationship with its delegates. To ensure a successful partnership, Community Health group: Provides oversight to ensure compliance with federal and state regulatory standards, and NCQA standards for accreditation. Collaborates with delegated groups to continuously improve health service quality, including, but not limited to: population health management provide information and tools facilitate identification and sharing of best practices The Delegation Oversight Committee oversees the compliance of delegated activities with the signed delegated agreements. CHG monitors delegated compliance with standards through an annual oversight review. The review is conducted utilizing delegated audit tools developed for each specific area of delegation. The review of the appropriate policies and procedures, programs, and files may require an improvement action plan. The improvement action process includes follow-up tracking of compliance in accordance with stated time frames. Delegated oversight review results are reported to the QIP committees as appropriate and the CorpQIC. 49 QIP 2015

56 There are policies and procedures in place to ensure delegates compliance with the defined policies and standards. Delegation of activities is based on an initial assessment and on-going monitoring and oversight. Community Health Group retains accountability for all delegated functions. If the delegated activities are not being carried out in accordance with the terms of the delegation agreement and/or improvement action plan, corrective action (up to and including revocation of delegated status) may be implemented. Community Health Group does not delegate Quality Improvement activities; however, IPAs/Medical Groups are expected to perform certain QI functions as an augmentation to CHG s QI Program. These activities include, but are not limited to: Written QI Program Description Active QI Committee Annual QI Program Evaluation Annual QI Work Plan Regular reports of QI activities Annual Quality Improvement Work Plan Annually the QI Department develops a QI Work Plan for the calendar year. The Work Plan integrates QI reporting, studies from all areas of the organization (clinical and service), and includes requirements for external reporting. The QI Work Plan is also based on the results of the annual program evaluation. The Work Plan includes the following elements: Measurable objectives for each QI activity planned for the year, including: Quality of clinical care, Safety of clinical care Quality of service and Members experience/satisfaction. Program scope. Activities planned for the year, the quality, and safety of clinical care and service indicators, benchmarks, performance goals, and previous year results. Time frame within which each activity is to be completed. The person responsible for initiation, implementation, and management for each activity. Planned monitoring and follow-up activities from previously identified issues. Time frame for evaluation of the effectiveness of the QI Program. Scheduled reports to the CorpQIC and Board of Directors. Scheduled reporting to external regulators (e.g., DMHC, DHCS). The oversight of reporting delegated activities. Schedules of all planned quality activities (e.g. member satisfaction surveys, practitioner compliance surveys). Corporate divisions and QIP Committees utilize the work plan to manage projects and the Corporate Quality Improvement Committee and the Board of Directors to monitor progress. The Work Plan may be modified throughout the year with approval from the CorpQIC. Modifications are reported to the Board of Directors and appropriate QIP Committees and Sub-Committees. QIP

57 Approval of the Quality Improvement Program Annually, following each review and update, the Quality Improvement Program Description and Work Plan is reviewed and approved by the Corporate Quality Improvement Committee, the Chief Executive Officer, and the Board of Directors. The approval process includes the authorized signatures at each level of review. The program is not considered final until approval by the Board of Directors. 51 QIP 2015

58 QIP Quality Improvement Program Description

59 Utilization Management Program Description Philosophy The Utilization Management (UM) Program applies to all healthcare management activities, including behavioral health care, performed by Community Health Group, under the direction of the Chief Medical Officer (CMO). Community Health Group is committed to managing resources effectively and efficiently while ensuring quality healthcare delivery. Community Health Group works in partnership with members and practitioners to promote a seamless delivery of health care services. Community Health Group s managed care programs balance a combination of benefit design, reimbursement structure, information analysis and feedback, consumer education, and active interventions to control cost and improve quality. Purpose Utilization Management is the process of influencing the continuum of care by evaluating the necessity and efficiency of health care services and effecting patient care decisions through assessments of the medical appropriateness of care. The purpose of the Utilization Management Program is to implement a comprehensive integrated process that actively coordinates, directs, and monitors the quality and cost effectiveness of health care resource utilization at all levels within Community Health Group. The UM Program assists in ensuring that services are available in a timely manner, provided in appropriate settings, and are planned, individualized and evaluated for effectiveness. The UM Program also serves to promote safe, accessible and timely delivery of care. The UM Program promotes continuum of care principles that integrate a range of services appropriate to meet individual member needs while maintaining flexibility in adapting services as needs change. Scope The UM Program, using the principles of continuous quality improvement, monitors the delivery of health care services provided to all members. It applies to all utilization management activities performed by Community Health Group. These activities include all types of care (primary, specialty, including behavioral health, ancillary); all sites and levels of care (e.g., ambulatory, inpatient, home health, skilled nursing, hospice); and all aspects of care (e.g., preventive, diagnostic, treatment, palliative). Community Health Group is accountable for all the utilization management activities conducted for its members. Although parts of utilization management may be delegated to other entities, Community Health Group retains accountability for the decisions made by these entities. Community Health Group is responsible for assuring that members receive equitable access to care and service across its network. 53 QIP 2015

60 The scope of the UM Program is to: Ensure that health care services provided are medically necessary; Manage benefit resources effectively and efficiently while ensuring quality care is provided; Make utilization decisions based on sound, objective clinical evidence, taking individual circumstances and the local delivery system into account; Identify and resolve inefficiencies in resource utilization; Assess the effect of cost containment activities on the quality of care delivered; and Identify and coordinate with Quality Improvement in the management of quality of care issues or trends. Goals The goals of the Utilization Management Program are as follows: Ensure the provision of medically necessary and appropriate services to members Promote the delivery of quality medical and behavioral health services at the appropriate level of care in a timely, cost effective and efficient manner Continually monitor, evaluate and optimize the use of health care resources; identify events and patterns of care in which outcomes may be improved through efficiencies in utilization management, and institute actions to improve performance Develop, adopt, review, evaluate and update criteria for the authorization of health care services to members Monitor utilization practice patterns of participating practitioners, hospitals and ancillary service providers Educate members, practitioners, hospitals and other ancillary providers about Community Health Group s goals for providing high quality, cost-effective managed health care Maintain an overall perspective of members health needs to explore creative alternatives for delivery of care that ensure the most appropriate and cost-effective treatment methodologies Ensure coordination of activities between quality improvement and utilization management Identify and assess the need for case management through early identification of high or low utilization of services, high cost, chronic or long-term diseases Promote health care in accordance with local, state and national standards and regulations Ensure timely responses to appeals and grievances Objectives The objectives of the UM Program include: Review and evaluate health care services for quality, medical necessity, appropriate level of care and discharge planning needs; Support communication and flow of information between the Chief Medical Officer, the UM Committee, the Clinical Quality Improvement Committee, and the Quality Improvement Committee; Ensure confidentiality of member and practitioner information; QIP

61 Review utilization data identifying over-and under-utilization practices, and to identify and implement programmatic improvements that enhance appropriate utilization; Ensure consistent application of UM functions across all product lines; and Evaluates member and practitioner satisfaction at least annually. Functions Components of the UM Program include: Prior Authorization. Authorize and arrange for medical, facility, and ancillary services using criteria to determine medical necessity and following established timeliness standards. (Policy Referral and Prior Authorization System, Policy Timeliness of UM Decisions, Policy Review of Requests, Policy , Clinical Criteria ) Urgent Care Triage. Provide screening of member calls to the telephone advice nurse of an urgent nature and to coordinate care with the Primary Care Practitioner (PCP) or his/her designee. Emergency Services. Provide, arrange for or otherwise facilitate all needed emergency services, including appropriate coverage of costs, 24 hours a day, seven days a week. Medical Necessity and In-patient Case Monitoring. Coordinate and conduct data collection for medical necessity, quality of care, appropriateness of hospital admission, coordination with other member benefit plans, level of care and continued inpatient stay as required. This review is performed cooperatively with the hospital's utilization review personnel through on-site or telephonic review and substantiates the medical necessity and level of care for members in an inpatient status. Discharge Planning. Identify discharge planning and case management needs for hospitalized members in conjunction with discharge planning and/or case management personnel at participating hospitals and coordinating with the member s PCP and IPA, when applicable. Case Management. Assist the PCP and site case managers with the development of a case management plan to meet the needs of Community Health Group members. Serve as an on-going resource to the PCP and site case managers regarding case management of individual members. Assist with a member s transition to other care, if necessary when benefits end. Community Health Group s High Risk/Chronic Care Case Managers address the needs of members who have been hospitalized at least once for recurring or chronic conditions. The objective of these case managers is to prevent hospitalization by maximizing outpatient modalities, such as prompt referral to specialists, quick access to primary care, medication management, health education, and home health. These case managers maintain regular contact with targeted members to assist members with their care plans and to provide necessary follow-up. Behavioral Health Care. Authorize, coordinate, and arrange for in and out-patient care; facilitate the coordination of physical and behavioral health services; and evaluates sites of service and levels of care. 55 QIP 2015

62 Quality Monitoring. Perform quality reviews on hospitalized members and screen ambulatory referrals for quality of care indicators. Eligibility and Benefits Verification. Verify member eligibility, benefits coverage and physician/hospital contract status at the time of authorization. Appropriateness of Service Monitoring. Review member and practitioner utilization data to evaluate the appropriateness of care provided and detect potential over and under utilization. Post-service Review. Review selected cases retrospectively for medical appropriateness and level of care. Network Education. Provide ongoing education to network practitioners and ancillary providers on medical criteria, clinical practice guidelines, disease management protocols, preventive services guidelines, pharmaceutical advances, and technology assessment. Notification of Medical Necessity Determinations. The Chief Medical Officer or designee, who is also a California-licensed physician, determines the recommendation and notifies the attending physician in writing of the decisions and the right to appeal. The letter includes the reason for the denial, modification, or delay; criteria used; phone number of physician who rendered the decision; and clearly outlines the appeal process and member s right to independent medical review. Expedited appeals language is included on all denial letters. Failure to meet authorization criteria at the time of authorization review may result in denial, modification or deferral of a request for service. (Policy Timeliness of UM Decisions ) Technology Assessment. Reviews and assesses treatment, tests, medical and behavioral health procedures, devices, equipment, and drugs to determine their clinical- and cost-effectiveness; seeks input from relevant specialists and professionals who have expertise in the technology evaluated; communicates these findings to clinicians to assist them in making evidence-based decisions; assists in the education of members in understanding the impact of technology on their health and quality of life; ensures that members have equitable access to safe and effective medical care. Community Health Group s Technology Assessment Committee, a sub-committee of the Utilization Management Committee, Technology assessment is not a UM function that is delegated to any entity. Disease Management. The Utilization Management Program incorporates Community Health Group s disease management programs and clinical practice guidelines. Activities and medical review criteria are consistent with established program and initiatives. Accountability and Organizational Structure Board of Directors (Board). The Board of Community Health Group has ultimate responsibility for the quality and cost effectiveness of the health care delivered to Community Health Group s members whether services are arranged for or directly provided by a contracted entity. The Board delegates this responsibility to the Chief Medical Officer. The Board receives, at a minimum, a quarterly summary of all Utilization and Quality Improvement activities, including findings and actions taken by the Utilization Management Committee. The Board provides feedback to the Utilization Management Committee via the Chief Medical Officer. QIP

63 Chief Medical Officer. Community Health Group's Chief Medical Officer, who holds an unrestricted license to practice medicine in the state of California, is responsible for the overall direction of the Health Care Services Division including monitoring the implementation of the Utilization Management and Quality Improvement processes and ensuring that corrective actions are taken when appropriate. The Chief Medical Officer or Medical Director reviews services not meeting review criteria. Decisions that initiate a modification or denial of service(s) are made at the physician level. Medical Director. The Medical Director, who holds an unrestricted license to practice medicine in the state of California, is responsible for reviewing requests for services that do not meet clinical review criteria and may initiate the modification or denial of services. The Medical Director provides clinical direction to second and first level reviewers. Behavioral Health Practitioner. The designated Behavioral Health Practitioner is a licensed psychologist and is responsible for the overall clinical direction of all behavioral health services covered by the appropriate line of business. The Behavioral Health Practitioner is actively involved in implementing the behavioral health aspects of the UM program including setting policies, participating in credentialing, reviewing potential denials and participating on the UM Committee. The Behavioral Health Practitioner is also actively involved in assuring continuity and coordination of care between medical and behavioral health practitioners and assists in developing programs focused on coordination of care. Chief of Operations. The Chief of Operations, in conjunction with the Community Health Group Chief Medical Officer, provides oversight of utilization, disease, and case management, medical quality management and behavioral health management activities. The Chief of Operations is responsible for the coordination of the operational components of the Utilization Management Program. The Chief of Operations is responsible for coordinating the oversight of delegated UM activities and compliance with applicable delegated agreements. Director of Pharmacy Services. The Director of Pharmacy Services, under the supervision of the Chief Medical Officer and Chief of Operations, oversees the areas of behavioral health, disease management, community and preventive services, and pharmacy services.. The Director of Pharmacy Services serves as the co-chair of Community Health Group s Pharmacy & Therapeutics Committees and is actively involved in ensuring the integration of drug therapy with all aspects of medical and behavioral health. Director of Utilization Management Services. The Director of Utilization Management Services is responsible for the supervision of staff performing utilization review (pre-service, concurrent, and retrospective) and high risk case management. The Director of Utilization Management Services manages the all aspects of the UM program and serves as the co-chair of Community Health Group s UM Committee. The Director of Utilization Management Services also manages staff performing out-patient review and the supportive functions to the UM Department, including but not limited to the UM call center and help desk, intake and document management, UM notification and correspondence, and data entry. Behavioral Health Services Program Manager. The Behavioral Health Services Program Manager manages the operational aspects of the provision of behavioral health services as covered by lines of business and coordination with physical care. The Behavioral Health Services Program Manager works closely with the Contracting Department to maintain a network of practitioners to meet the needs of CHG s members. 57 QIP 2015

64 Primary Care Practitioners (PCPs). The primary care physician, along with designated site case managers, is the primary case manager of each member. The Primary Care Practitioner ensures the coordination of medically necessary health care services, assuring the provision of preventive services in accordance with established standards and periodicity schedules and ensuring continuity of care for members. This includes a health risk assessment, treatment planning, coordination, referral, follow-up, and monitoring of appropriate services and resources required to meet an individual s health care needs. Community Health Group Case Managers. Community Health Group Case Managers authorize and administer health care benefits based on eligibility and benefit coverage; direct members to the appropriate contracted hospitals and providers; evaluate medical necessity, proposed place of treatment and treatment plans for members referred for non-primary Care Practitioner services; ensure that all specialty referral services are provided under the direction or concurrent agreement of a designated Primary Care Practitioner, coordinate requests for care outside of the referral network with the Primary Care Practitioners; review inpatient services to ensure that medically appropriate care is provided in a quality manner to members; provide oversight and assist practitioners with case management activities; and manage high-risk and members with chronic diseases. Intake Specialists. Intake specialists verify eligibility and benefit coverage and perform first level review by approving services following specific protocols and provide administrative support to Community Health Group Case Managers. Data Analyst/Statistician. The Data Analyst/Statistician abstracts data and creates reports that assist in the identification of utilization patterns and trends (e.g., under or over-utilization of services, appropriate level of care of services); supports disease management programs and initiatives; and ensures the statistical validity of reports and analysis. Behavioral Health Services Unit. The Behavioral Health Services Unit coordinates behavioral health care as covered by lines of business and provides information, referral and case management services along with advocacy for members in need of mental health and substance abuse services. Behavioral health services are available to members 24 hours a day via a toll-free number. A designated behavioral health practitioner advises Community Health Group in the implementation of the behavioral health care aspects of the UM program. Behavioral health care practitioners also participate on committees, as necessary. A psychiatrist or psychologist reviews any behavioral health denial of care based on medical necessity. Telephone Advice Nurse (TAN). A registered nurse (RN) is available to Community Health Group members through a dedicated toll-free number 24-hours a day to provide medical triage, advice, and education per standardized criteria. TAN encounters are documented and sent via facsimile to Primary Care Practitioners within 24 hours. (Policy PCP Instruction for Emergency Room Department and TAN Program ) Information Systems Staff. Information systems staff is responsible for overseeing the data warehouse, maintaining and supporting the case management/utilization management and quality improvement software, and providing regular and ad hoc reports to monitor under and overutilization. Contracting Department. The Contracting Department assures language in contracts and delegated agreements supports the Utilization Management Program and responds to requests for new QIP

65 practitioner and ancillary contracts. Compliance Officer. The compliance officer assures that Community Health Group is aware of and is in compliance with all regulatory requirements. Hospitals. Participating hospitals are responsible for verifying authorization for elective admissions and outpatient services; communicating with Community Health Group s Case Managers regarding the current intensity and level of services provided; notifying CHG within 24 hours or one business day of emergency services and/or admissions of members; and coordinating discharge planning with Community Health Group Case Managers. Delegated Entities. Contracted network entities that qualify for delegation of utilization management functions and responsibilities are evaluated as part of the pre-contractual assessment process and reviewed and approved by the Utilization Management Committee. Delegation of this responsibility is contingent upon these plans effectively meeting the requirements contained in Community Health Group s Utilization Management Program. Delegated Utilization Management entities are regularly reviewed to monitor compliance with these requirements. Utilization Management Committee The Utilization Management (UM) Committee is a group of actively practicing practitioners and Community Health Group personnel that serves to facilitate the implementation of the Utilization Management Program. Input is additionally solicited from the members of the Plan s healthcare delivery system. The Committee is a sub-committee of the Quality Improvement Committee. It serves as a review body for problem identification, action, resolution and confirmation of corrective measures. (Refer to QIP Diagram, Appendix A.) The Utilization Management Committee is comprised of practicing, contracted physicians with diverse representation (including at least two who are primary care physicians representing Internal Medicine, Family Practice, and/or Pediatrics, and ancillary providers who are representative of the Plan s healthcare delivery system. The UM Committee also includes the following Community Health Group staff: Chief Medical Officer (serves as the committee chair) Director of Utilization Management Services (co-chair) Director of Pharmacy Services Behavioral Health Practitioner Behavioral Health Services Program Manager Registered Nurse Case Management representative Responsibilities. The responsibilities of the Utilization Management Committee include the following: Review of Authorization Criteria. The Committee is charged to develop, review, evaluate and update Community Health Group s criteria for the authorization of health care services to members. Advisory Panel. Each member of the Committee serves in an advisory capacity to the Chief Medical Officer when such services are needed, particularly on an emergent or urgent basis. 59 QIP 2015

66 Utilization Data. The Committee provides input to reports distributed to contracted physicians. Utilization data is reviewed as a means of: comparing individual practice patterns to those of other Community Health Group practitioners; determining practitioner practice outliers and a method for recommending process improvements; monitoring the effectiveness of recommended changes to practitioners practice patterns; and identifying either under- or over-utilization patterns and implementing improvement action plans. Review for Aberrant Practice Patterns. The Committee reviews potential aberrant practice patterns or potential fraudulent activity identified by the Case Management Department, Claims Department, Pharmacy Services Department, and/or the Quality Improvement Department and recommends corrective actions and/or policies and procedures to prevent recurrence. Quality of care issues are referred to the Quality Improvement Committee for action or review, tracking and trending. Recommendation and Implementation of Corrective Action. The Utilization Management Committee may recommend corrective action, including practitioner sanctions, when trends or patterns of inappropriate health care resource use are identified. Such corrective actions may include formal or informal educational programs. The "Provider Fair Hearing" policy outlines procedures for imposing sanctions. Statistical Outcome Studies. The Utilization Management Committee, in conjunction with the Quality Improvement Committee and Pharmacy & Therapeutics Committee, produces statistical outcome studies utilizing information obtained from Community Health Group's management information system that: support the process of evaluation and continuous quality improvement of the clinical process; identify those clinical processes which are statistically more effective than others in order to provide a resource for clinical quality improvement; and disseminate appropriate health care information to practitioners that will assist in promoting improved quality and cost effectiveness in health care. Establishment of Medical Care Studies and Criteria. The Committee may develop special studies to identify at risk populations for disease management programs and utilization and/or quality problems that affect the outcome of member care wellness. Medical records will be provided for the Committee's review when there is evidence of aberrant use of Plan resources. If a specialty area is not represented on the Committee, the Chief Medical Officer or the Committee may delegate the review to a qualified specialist or request a local qualified specialist to participate on the Committee for the review. Quality of care issues will be referred to the Quality Improvement Committee for action or review and trending. Recommendations will be made regarding population and disease management programs. QIP

67 Utilization Management Program. Periodically, but at least annually, the Committee will review the Utilization Management Program for effectiveness and appropriateness. Member and practitioner satisfaction is included in the evaluation process. The Committee will review and approve revisions of the Utilization Management Program and recommend approval to the Quality Improvement Committee. The Quality Improvement Committee will review the revisions and make recommendations to Community Health Group's Board of Directors for their approval. Meetings. Meetings are held on a quarterly basis, at a minimum. Ad hoc meetings are held at the discretion of Community Health Group's Chief Medical Officer to: ensure compliance with policies, procedures and recommendations, of the Committee; provide a forum for timely evaluation and revision of the Plan's criteria; and ensure that appropriate and medically necessary services are provided to members. The proceedings of the UM Committee are reported on a quarterly basis at the Corporate Quality Improvement Committee. Conflicts of Interest. Health care providers who participate on the UM Committee agree that their participation, decision-making, and/or voting relating to the Committee s activities are unhindered by any fiscal or administrative constraints, arising from Community Health Group, any entity contracting or doing business with Community Health Group, or any pharmaceutical or medical supply or device researcher, manufacturer, distributor, or seller. Committee members agree to make fair and impartial recommendations, decisions, and/or votes concerning issues before the Committee. In the event of a potential or actual conflict of interest, the involved Committee member may participate in the Committee s discussion but will abstain from casting an official vote on issues to which the potential or actual conflict of interest may be relevant. (See Appendix C). Technology Assessment Sub-Committee Community Health Group has a formal mechanism to evaluate and address new developments in medical technology. The Chief Medical Officer serves as the Chairperson of the Technology Assessment Sub-Committee (TASC), which is a sub-committee of the Utilization Management Committee. Objective criteria considered includes demonstrated improvement in health outcomes, extent of health risks and health benefits derived from the new technology when compared with established procedures and products, documented indications and contraindications, alternative modes of treatment and cost. Scientific evidence and determinations from recognized regulatory bodies are components of the review process and form a basis for decision-making and criteria formation. Professionals with expertise related to the technology under review participate in the evaluation of new and existing technology and in the creation of criteria for its application. The TASC communicates the results of reviews to the Utilization Management Committee for approval. Results of the review are also communicated to the Benefit Interpretation Committee and, where appropriate, to the Pharmacy & Therapeutics Committee and Network Practitioners. 61 QIP 2015

68 Purpose. The purpose of the TASC is to provide an integrated system and process for the review and assessment of existing and emerging medical technologies, medical and behavioral health procedures, pharmaceuticals, and devices on an as-needed basis. Reporting Relationships. The TASC receives input from the Chief Medical Officer and other who may assist with undertaking a review, such as: Director of Pharmacy Services Director of Utilization Management Services Registered Nurse Case Manager Behavioral Health Practitioner Behavioral Health Services Program Manager personnel performing literature searches and reviews external experts The TASC may also review recommendations of the Pharmacy & Therapeutics Committee related to the assessment of new and existing drugs. The TASC reports its activities and results of reviews on a quarterly basis to the UM Committee for approval. Results of reviews are also communicated to the Benefit Interpretation Committee at a minimum on an annual basis and, where appropriate the Pharmacy & Therapeutics Committee. Membership. TASC members include: Community Health Group Chief Medical Officer( serves as sub-committee chair ) Director of Utilization Management Services (co-chair) Director of Pharmacy Services Registered Nurse Case Management representative Behavioral Health Practitioner Behavioral Health Services Program Manager Clinicians who are credentialed and contracted by Community Health Group for both primary care and specialty care (including behavioral health). Clinicians and external experts who are not credentialed nor contracted may be invited as guests of the sub-committee. Roles and Responsibilities. The Community Health Group Chief Medical Officer will: chair the Technology Assessment Sub-Committee; respond to all requests for technology review; disseminate the results of reviews to network clinicians; communicate the results of reviews to the Benefit Interpretation Committee and, when appropriate, the Pharmacy & Therapeutics Committee; communicate the results of reviews, as appropriate, to plan members, IPA and medical group administrators; and Community Health Group staff such as those involved with utilization and case management, quality improvement, pharmacy management, membership services, benefit administration, contracting and claims processing; and monitor the use of recommended technologies through utilization and case management and forward any quality of care concerns that arise in their use to the Quality Improvement department for review and follow-up, as needed. QIP

69 Sub-committee members will: attend meetings of the TASC; complete reviews using objective criteria and appropriate resources; follow CHG s evaluation process to make determinations; review information from appropriate government regulatory bodies; review of information from published scientific evidence; and seek input from relevant specialist and professionals who have expertise in the technology. Clinicians will: review recommendations and forward disagreements or suggested changes or requests for rereview to the sub-committee; and monitor the effectiveness, risks and benefits of sub-committee recommendations for patients, and report findings to the Chief Medical Officer. TASC decisions and recommendations will be made by consensus. Meeting Frequency. Meetings are held at least four times each year, with ad hoc meetings as necessary, or called by the chairperson. Utilization Management Staffing, Qualifications, Training Staffing. Utilization management activities are coordinated and conducted under the direction of the Chief Medical Officer. Managers and supervisors oversee the daily functions of the UM Program. The utilization management staff works as a team to cover all geographic areas, facilities, and product lines. The staff includes: Medical Director Third Level Reviewer as described below; with Chief Medical Officer, reviews all denials, modifications, and deferrals registered nurses Second Level Reviewers as described below intake specialists First Level Reviewers (non-clinical) as described below administrative support staff call center, document management, UM correspondence, data entry pharmacist with Medical Director, reviews pharmacy modifications and denials pharmacy technical support First Level pharmacy review behavioral health specialists psychologists and psychiatrists; review all behavioral health service denials, modifications, and deferrals behavioral health administrative staff oversee operational (non-clinical) aspects of behavioral health services Staff Qualifications. Community Health Group employs qualified individuals with licensure and experience specific to the job requirements. Appropriately licensed health professionals conduct all review decisions. Those with the qualifications listed below perform decisions requiring clinical judgments. First Level Non-clinical Reviewer. First level reviewers may approve services following specific protocols developed by Community Health Group s clinical staff. Services specified for approval by nonclinical reviewers include services that are generally approved given specific diagnosis or situations and do not require the reviewer to exercise clinical judgment. Initial behavioral health consultations are 63 QIP 2015

70 included in services authorized by first level review. Services authorized by non-clinical reviewers are monitored through reports. Qualifications include: Training and testing (90% minimum score) on ICD-9, CPT, and medical definitions; Training and testing (90% minimum score) on application of Community Health Group s benefit and provider grids; and Clinically supported by a licensed clinical reviewer. Second Level Clinical Reviewer. Second level reviewers conduct the initial clinical review of health care services requests against medical appropriateness criteria. The second level review is generally conducted by registered nurses or other licensed health professionals. Qualifications include: Current state licensure; Adequate training to utilize medical appropriateness criteria and applicable review of standards or medical policy; and Clinically supported by a licensed physician or clinical peer. Third Level Peer Reviewer. The Chief Medical Officer or Medical Director conducts clinical review of services that do not meet initial clinical review appropriateness criteria. In addition, services that have a specific requirement for authorization, as noted by medical policy, are reviewed at this level. Qualifications include: Current non-restricted license to practice medicine in California; Education, training or professional experience in medical or clinical practice; Adequate training to utilize medical appropriateness criteria and other applicable review standards or medical policy; Ability to review cases for which a clinical decision cannot be made by the second level reviewer; and Reasonable availability, within one business day, to discuss clinical determinations with the attending or ordering physician. Fourth Level - Peer Clinical Reviewer. Consultations and appeal reviews are conducted by fourth level or clinical peer reviewers. Qualifications include: Current non-restricted license to practice medicine or related health profession in California; Board certification in the same or similar specialty as usually manages the medical condition, procedure or treatment under review; and Oriented to the principles and procedures of the UM Program and the medical appropriateness criteria and other standards or medical policy. Staff Training. A formal program of orientation and training applies to clinical reviewers at all levels. Staff is trained in the concepts, components and processes of Utilization and Case Management. Inter Rater Reliability. Monitoring and peer review is performed at a minimum annually at all professional staff levels, including physicians, to ensure consistency among reviewers. The UM Committee actively assists in monitoring tool development and evaluation. All professional staff receives annual performance evaluations, and periodic progress reviews. QIP

71 Decisions Made Without Regard to Financial Incentives. Community Health Group distributes to all its members, practitioners, providers, and employees who make UM decisions a statement describing its policy on financial incentives and requires practitioners, providers and staff who make utilization-related decisions and those who supervise them to sign a document acknowledging that they have received the statement. This statement affirms that: UM decision making is based only on appropriateness of care and service and existence of coverage; Community Health Group does not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service care, i.e., compensation is not related to review decisions; and Financial incentives for UM decision-makers do not encourage decisions that result in underutilization. Confidentiality Community Health Group is committed to preserving the confidentiality of its members and practitioners. All employees, participating practitioners, providers and consultants will maintain a standard of ethics and confidentiality regarding both patient information and proprietary information. Written policies and procedures are in place to ensure the confidentiality of patient information and records. Patient information gathered to facilitate utilization reviews and claims administration is available only for the purposes of review and is maintained in a confidential manner. Records requested from practitioners are those that will provide relevant information to complete reviews or facilitate adjudication of claims. Training includes appropriate storage and disposal of confidential information. Documents of a sensitive or confidential nature are shredded prior to disposal. Employees receive and sign a confidentiality agreement at the time of their initial company orientation. Employees are also required to use approved passwords for member information access. Breach of confidentiality is considered a serious offense and will result in disciplinary action up to and including termination. The confidentiality process is extended to practitioners by verification, during compliance surveys, that policies and procedures exist to prevent unauthorized or inadvertent disclosure of confidential information. All committee minutes, reports, medical records, audits, studies, worksheets, documentation of utilization management activities and other data are maintained in a manner ensuring strict confidentiality. They are made available, upon request, for review by the Committee, appropriate Community Health Group management staff and regulatory bodies (as required). All Committee members and invited guests to the Utilization Management Committee sign a confidentiality statement that is kept on file. Integration and Linkage with Other Activities The utilization management staff and the Chief Medical Officer plan, coordinate and direct the operation of the UM Program. Representatives from the Utilization and Quality Improvement (QI) departments participate in the UM Committee and the Clinical Quality Improvement Committee. UM 65 QIP 2015

72 staff report identified quality issues and trends to the QI staff. Data collected and reported through the committee process is reported back to QI for development of practice standards and quality improvement plans to improve outcomes. Utilization management issues that are revealed during the QI process are reported to UM via the committee structure. Integration with other departments includes, but is not limited to the Preventive Services Department Provider Relations, Member Services, and the Credentialing Department. Case management and behavioral health staff work with the member, the member s PCP, and Member Services to coordinate care when a new member is receiving covered services from a non-participating provider, when a contract is discontinued between Community Health Group and a provider and when member s benefits end. Communication Services Community Health Group provides access to staff for members and practitioners seeking information about the UM process and the authorization of care. The following communication services are provided to practitioners and members: Availability of staff at least eight hours a day during normal business days for inbound calls regarding UM issues; Ability of staff to receive inbound communication after normal business hours regarding UM issues; Outbound communication from staff regarding inquires about UM during normal business hours, unless otherwise agreed upon; Staff identifies themselves by name, and title and indicates that they are calling from Community Health Group when initiating or returning calls regarding UM issues; A toll-free number regarding UM issues (Member Services Department); Access to staff for callers with questions about the UM process; TDD/TTY services for deaf, hard of hearing or speech-impaired members; and Language assistance for members to discuss UM issues. The Member Services Department has an established documented process that addresses when a Member Services Representative should transfer callers to the UM staff. Medical Review Criteria Community Health Group utilizes standardized review criteria that are evidenced based and supported by documented references and internally developed medical criteria for making decisions concerning medical necessity and appropriateness of services. The definition of medical necessity will be based on program regulation. In cases where there is an overlap between the coverage of benefits (e.g., the coverage of durable medical equipment services by Medicare and Medi-Cal), the definition of medical necessity that is the more generous of the applicable standards will be applied. Criteria are available and practitioners are informed of the use of criteria and how to obtain them through the Provider Update, Provider Alert, newsletters and through Community Health Group s web site. In addition, as stated in the Provider Manual, practitioners may request copies of criteria from the health care services division. The review process is designed to ensure that medically necessary services are provided in a uniform and timely manner to members. QIP

73 The primary review criteria utilized by Community Health Group in the authorization/review process are the Healthcare Management Guidelines (HMG) (developed by Milliman.) The HMG's were prepared by Richard Doyle, MD, along with the help of a team of practicing specialty physicians, health actuaries, and other qualified medical and risk management professionals. These evidence-based, nationally recognized and accepted guidelines are the primary criteria that Community Health Group staff apply when determining the appropriateness of an admission or inpatient length of stay or the medical necessity of a requested service. The HMGs by Milliman are the primary criteria for reviewing the appropriateness of behavioral health services. During the review process Case Management staff may additionally consult and apply a variety of peerreviewed criteria, guidelines and reference tools to assist in the medical appropriateness determination. Case managers apply criteria to individuals on a case-by-case basis and consider the individual s age, comorbidities, complications, progress of treatment, psychosocial situation, home environment, and any other individual needs when applicable; as well as the capabilities of the local health care delivery system. Additional internally developed authorization/review criteria may be developed from various references to supplement the primary HMGs in the case where a procedure/service is not addressed in the primary criteria. These reference tools include, but are not limited to: Peer reviewed medical appropriateness criteria Standard quality indicators (National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS); American Medical Association (AMA) specialty guidelines and state or county medical association guidelines; Length of Stay (LOS) by Diagnosis and Operation, United States (developed by HCIA, Inc.); Governmental agencies such as Centers for Disease Control, Food and Drug Administration, Agency for Health Care Policy and Research, National Institutes of Health; Local/regional agencies (State and County health departments); Non-profit health care organizations (e.g., American Heart Association, American Diabetes Association, American Lung Association); Peer-reviewed periodicals and journals; Consultation with actively practicing physicians who are appointed to teaching faculties, research foundations and/or members of recognized specialty societies; and Standards of Practice for Case Management of the Case Management Society of America (CMSA). Development Process. The process for developing or adopting authorization/review criteria is as follows: In the formation of the internal authorization/review criteria, Community Health Group references the above-mentioned tools. Based on research of the reference materials identified above, a draft of the medical review criteria is formulated or adopted by the Director of Utilization Management Services with input from the Chief Medical Officer and appropriate, actively practicing health care providers and practitioners. The draft criteria may be distributed to all or a subset of practitioners for additional review and input. 67 QIP 2015

74 The Director of Utilization Management Services is responsible for presenting the draft criteria to the Utilization Management Committee for review, recommendation, adoption and/or approval. A summary of newly-developed review criteria activity is reported to the Board of Directors through the Chief Medical Officer's (QIC) report. Additionally, finalized review criteria are available at Community Health Group for individual practitioner review with the Director of Utilization Management Services and/or Chief Medical Officer. Ongoing Review. As the outside reference materials described above are modified, the changes/updates are presented, as appropriate, to the Utilization Management Committee to ensure that criteria are updated as needed to incorporate current developments in clinical practice. The Utilization Management Committee reviews the new or revised guidelines and determines whether or not to adopt the changes. If adopted, the existing criteria will be modified to incorporate the recommendations of the Committee. The Director of Utilization Management Services then follows the same procedure as for newly-developed criteria. Annual Review. Periodically, but at least annually, the Utilization Management Committee reviews the Authorization/Review Criteria. The Committee makes appropriate change recommendations to the Quality Improvement Committee. Changes are communicated to contracted practitioners through Community Health Group's quarterly Provider Update newsletter, Community Health Group's Provider Alerts and individual mailers to each contracted Primary Care Physician and/or contracted applicable specialties as required. Urgent/Emergent Review. For criteria requiring immediate or urgent review, the Chief Medical Officer may call an ad hoc meeting of the Utilization Management Committee. The process for developing or modifying the Authorization/Review Criteria remains the same as mentioned above. Distribution of Criteria. Medical review criteria are available upon request to practitioners. Practitioners may receive a copy of individual criteria, review the entire set of criteria on site at Community Health Group, or may have sections read or faxed upon request. Practitioners are informed in the Provider Manual, provider newsletters and on Community Health Group s web site of the existence of criteria and how to request or review criteria. When a request for services is denied, both the member and practitioner are informed of the availability of the criteria used to make a determination and of how to obtain a copy. The development, review, update, and distribution of clinical review criteria are described in Policy Clinical Criteria for Utilization Management Decisions. Procedures for applying criteria are described in Policy Review of Requests for Health Care Services. The process for assessing the consistency in applying criteria is described in Policy 7273 Utilization Management Program Evaluation and Process Monitoring. Review of Requests for Health Care Services Community Health Group obtains relevant clinical information and consults with the treating physician when making a determination of coverage based on medical necessity. All information relevant to a member s care is considered when making a UM decision. QIP

75 Requests for services are reviewed to determine whether adequate supportive medical documentation has been submitted by the requesting practitioner to make a decision. Information required will be limited to that which is reasonably necessary to make a determination. The following member-based information is considered in making a utilization management decision: 1. diagnosis 2. severity 3. treatment tried, failed, or contraindicated 4. age 5. comorbidities 6. complications 7. progress of treatment 8. psychosocial situation 9. home environment, when applicable 10. urgency 11. benefit structure When it is necessary to conduct on-site review at facilities to obtain relevant clinical information, Community Health Group Case Managers follow established procedures. Community Health Group s policy requires that Case Managers abide by the check-in policy for third-party reviewer at each hospital, wear a CHG identification badge (picture ID) that is issued upon employment, observe the Joint Commission on Accreditation of Healthcare Organizations requirements that govern each hospital s policy, and observe the individual hospital s policies regarding member records. Upon employment, each CHG case manager receives training and orientation. The training and orientation schedule includes reviewing applicable facility contract language, facility contacts, and policies and procedures related to onsite reviews. When possible, a veteran CHG case manager will accompany a newly employed case manager to a facility for the first time. Denial Process The process of review, using established criteria, encompasses first, second, third, and fourth level reviews as described previously. A physician with a current California license to practice without restriction with education, training or professional experience in medical or clinical practice, reviews services that are deferred, modified, or denied. All denial decisions are followed with written notification to the requesting practitioner and member, as described in Policy 7254 Notification of Utilization Management Decisions." Denial decisions include, in easily understandable language, the rationale for the denial, reference to the benefit provision, guideline, protocol or other similar criterion on which a denial decision was based treatment alternatives, phone number and availability of the practitioner who rendered the decision, notification that the member can, upon request, obtain a copy of the actual benefit provision, guideline, protocol, or other similar criterion on which the denial decision was based, and information, in writing, about the appeals process, including the member s right to submit written comments, documents or other information relevant to the appeal, member representation and time frames, and independent medical review. Members are also notified about the expedited appeal process and that expedited external review can occur concurrently with the internal appeals process for urgent care and ongoing treatment. Decisions are made in the timeframes specified in Policy Timeliness of UM Decisions. 69 QIP 2015

76 Appeals Quality Improvement Program Description The purpose of an appeal is to provide a formal reconsideration or second look at a denial. The member, practitioner, facility or authorized representative of the member may submit an appeal on behalf of the patient. Two mechanisms for appeals of utilization management exist: Expedited appeal. An expedited appeal may be requested to change an adverse determination for urgent care or as a result of concurrent review. Expedited appeal requests may be initiated by telephone, fax, Community Health Group s web site, or in writing. Additional information for review must be submitted, and determinations are made as expeditiously as the medical condition requires, but no later than three calendar days (72 hours) after the request is made. Standard appeal. Standard appeals may be pre-service or post-service. Standard appeals must be initiated by submitting the request with additional information for review by telephone, writing, Community Health Group s web site or by fax within 180 days after notification of the denial. Determinations are made within 30 calendar days of receipt of required documentation for review. Appeals are reviewed by the interdisciplinary Grievance and Appeals Committee, which includes a physician not associated with the original review and who is not the subordinate of any person involved in the initial determination. The Committee may reverse a denial of services on appeal. However, when there is not a reversal of the decision and the denial is upheld, the appeal may be reviewed by a specialty-matched, licensed, board-certified physician or clinical peer at the reviewing physician s discretion. Additionally, in cases of denials based in whole or in part on medical necessity, members have a right to an independent medical review (IMR) by requesting that service through the state s Department of Managed Health Care. The member handbook provides educational information regarding the appeals process. In addition, the Provider Manual provides appeal information to practitioners and other providers. All denial correspondence and explanation of benefit (EOB) statements include information regarding the appeals process. The appeals process is further described in Policy Medicare Complaints, Grievances and Reconsiderations. Delegated Utilization Management Contingent upon an entity effectively meeting the condition for delegation, Community Health Group may delegate some of its Utilization Management functions to practitioner groups with the exception of the appeals process and technology assessment. The Delegation Oversight Committee oversees the compliance of delegated activities by means of the signed and mutually agreed upon, Delegation Agreement for Utilization Management Services Agreement. Through the Delegation Program, Community Health Group retains responsibility for assuring compliance with performance standards while giving a contractor the authority to perform designated functions on its behalf. Medical groups with delegated utilization management maintain responsibility for conducting the referral and authorization processes set by the benefit plan, contractual agreement(s) (including a delegation agreement signed by both parties) and Community Health Group s utilization management standards, as set forth in the Utilization Management Program and delegation policy. QIP

77 Community Health Group s Chief Medical Officer, who holds an unrestricted license to practice medicine in the state of California, is responsible for Delegation Oversight. Community Health Group performs an initial assessment of the delegated entity s capacity to perform the activities and ongoing oversight of delegated utilization management functions. The goal in conducting oversight is to review all processes of the delegated medical group to ensure appropriate utilization and quality of services. Oversight functions include review of: Annual review and approval of delegate s Utilization Management Program; Utilization Management summary of activities and semi-annual/annual reports; Appeal log with outcome of appeals (to monitor that delegated entity is not performing this function on Community Health Group s behalf); Denials made by the delegated medical groups which is assessed by file review; Member and practitioner satisfaction surveys; and Annual evaluation (on-site review) of delegate s performance. Delegation of utilization management responsibility by Community Health Group is contingent upon the delegated entity effectively meeting the requirements contained in the mutually-signed Delegated Agreement for Utilization Management. The delegated agreement includes the responsibilities of Community Health Group and the delegated entity in terms specific to this relationship. The document clearly states the process for evaluating the delegate s performance. There is also an explicit statement regarding the consequences if the delegate fails to meet the terms of the agreement. Consequences may range from the development of corrective action plans, to additional audits of compliance by Community Health Group, to revocation of the agreement. (See attachment E, Delegated Services Agreement template and delegation grid.) The delegation agreement also describes the requirement for privacy and confidentiality protections if the delegation arrangement is not with a covered entity as defined in the HIPAA regulations. Delegation and oversight of utilization management activities is outlined in Policy 7271 Delegated Utilization Management. Utilization Management Program Evaluation and Process Monitoring Community Health Group evaluates its Utilization Management Program to assess the fairness, consistency, and appropriateness and timeliness of its utilization management decisions. The monitoring and evaluation process assures that the Utilization Management Program does not create a barrier to care and cause unnecessary problems for members and providers. This process is described in Policy 7273 Utilization Management Program Evaluation and Process Monitoring and Policy Review of Utilization Management Non-Certification Notices. Interrater-Reliability. Community Health Group reviews the consistency of decision made across all reviewers at least annually. Community Health Group acts on identified opportunities for improvement, if identified. Satisfaction with Utilization Management Process. Information is gathered through annual surveys from both members and practitioners regarding their level of satisfaction with Community Health Group s Utilization Management process. Both the Utilization Management and Quality Improvement Committee members are regularly surveyed regarding their experience with the utilization management 71 QIP 2015

78 process. Where opportunities for improvement are identified, Community Health Group takes action to change its processes to meet its goals and to meet members and practitioners expectations. UM Timelines and Denials Review. Community Health Group monitors and evaluates its utilization management process to its established policies and procedures. The evaluation process reviews timeline standards, notification timeframes, and compliance with health plan utilization management policies. Community Health Group takes action to change its processes to meet established guidelines when necessary. Annual Review of the UM Program. The UM Program is evaluated and the program description is updated annually based on regulatory and accreditation requirements as well as input from members and practitioners. It is approved by the UM Committee, and ultimately, the Board of Directors. QIP

79 Pharmacy and Therapeutics Committee The Pharmacy and Therapeutics Committee (P&T Committee) is an advisory group of health care professionals who serve as the organizational line of communication or liaison between physical, behavioral, and pharmacy providers and Community Health Group. The P&T Committee oversees the development, maintenance, and improvement of Community Health Group s formularies. The P&T Committee recommends policy on all matters related to the use of drugs to promote the clinically appropriate use of pharmaceuticals based on sound clinical evidence. The P&T Committee reports organizationally to Community Health Group s Quality Improvement Committee. The primary purposes of the P&T Committee are: Scope Advisory. The P&T Committee recommends the adoption or assists in the formulation of broad professional policies and procedures regarding evaluation, selection, procurement, distribution, use, safe practices and other matters pertinent to drugs. Educational. The P&T Committee recommends or assists in the formulation of programs designed to meet the needs of health care professionals (physicians, nurses, pharmacists, etc.) for complete, current knowledge on matters related to drugs and drug practices. The P&T Committee also recommends or assists in the formulation of programs and/or materials on drug information designed to meet the needs of Community Health Group Members. Utilization Management. The P&T Committee assesses the appropriateness, safety, efficacy, and costeffectiveness of empiric, therapeutic and prophylactic drug use through a structured on-going Drug Utilization Review (DUR) program. The DUR program encompasses the development, review, and evaluation of criteria for the authorization of non-formulary drugs. The Committee also assesses the service region to assure adequate Member access to pharmacy services. Structure Membership The P&T Committee is composed of no less than the representatives listed below: Committee co-chairpersons: Community Health Group s Chief Medical Officer Community Health Group s Director of Pharmacy Services (a licensed pharmacist with an unrestricted license to practice in California) 73 QIP 2015

80 Voting Members: Three (3) selected contracted, practicing physicians with diverse specialty representation (including at least two (2) who are Primary Care Physicians (PCPs) representing Internal Medicine, Family Practice, and/or Pediatrics) Minimum of two (2) selected contracted, practicing pharmacists Community Health Group s contracted Pharmacy Benefits Manager (PBM) Clinical Program Manager (clinical pharmacist) Community Health Group Staff Members: Pharmacy Technicians Corporate Quality Director (as needed) Behavioral Health Services Program Manager Non-voting Participants: Physicians of appropriate specialties as needed to evaluate specific classes of pharmaceuticals Additional staff as needed Guests Member Selection Criteria Physicians. Selected Community Health Group contracted physicians are invited to serve as voting members of the P & T Committee by the Chief Medical Officer and Director of Pharmacy Services. Selection is based on the following attributes: Availability/accessibility Board certification/eligibility Communication skills/diplomacy Credentials/re-credentials verification Interest/enthusiasm Knowledge/expertise Managed care knowledge/experience Medical/surgical experience Peer/personal recommendation Previous P&T committee experience QI audits results > average Reputation/ethical standards Specialty type. Pharmacists. Selected Community Health Group network pharmacists are invited to serve as voting members of the P&T Committee by the Chief Medical Officer and Director of Pharmacy Services. Selection is based on the following: Each pharmacist shall be registered and in good standing with the California Board of Pharmacy. Each pharmacist shall be currently and actively practicing at a contracted Community Health Group pharmacy. Each pharmacist shall have actively practiced for the past two (2) years. Availability/accessibility Communication skills/diplomacy QIP

81 Interest/enthusiasm Knowledge/expertise Peer/personal recommendation Previous P&T committee experience Reputation/ethical standards Term of Service Staff Participants. For staff participants, qualifications and term of service as a Committee member is determined by the duration of time a staff member holds the position that initially qualified him/her for Committee membership. Practitioners and Pharmacists. A practitioner and pharmacist selected to participate on the P & T Committee continues to serve as a voting member as long as she/he continues to meet the above stated criteria. Membership may be terminated when the practitioner or pharmacist: requests voluntary removal or is asked by the Committee co-chairpersons to resign due to any one of the following reasons: membership criteria no longer met attendance record of >50% unexcused absences develops major conflicts of interest beyond those addressed in the Conflict of Interest Statement (See Appendix C) conduct during meetings is disruptive and not conducive to effective, professional discussions and performance of business Meetings The P&T Committee shall no less than quarterly, and on an ad hoc basis. Additional individuals (employees or non-employees) may be invited to the meetings, when their specialized knowledge or experience would be of a benefit to the committee. A quorum consisting of either four (4) voting members or 50% of the voting members, whichever is less, must be present for the Committee to conduct business, unless the Chief Medical Officer (or designee) has attempted to reschedule and notify participants of the meeting and a quorum still does not exist. If a quorum cannot be assembled within thirty (30) minutes of the scheduled meeting, those in attendance will select an alternate date and time. If at the alternate meeting time a quorum is still not present and cannot be obtained within thirty (30) minutes, the Committee may either elect to meet and conduct business or disband. Record Keeping and Reporting Minutes. Minutes are recorded by Community Health Group staff and are maintained for each P & T Committee meeting. Minutes include, at a minimum, the name of the committee, date, time of the meeting, list of members present, and the names and titles of guests, when applicable. The minutes are recorded using Community Health Group s standard format and reflect the agenda item; relevant discussions; any actions, decisions, and recommendations; persons responsible to carry out action items; and due dates of action items. Minutes of the P & T Committee meetings are provided for review 75 QIP 2015

82 to the Committee members, the Quality Improvement Committee, and regulatory bodies (as required and applicable). Agenda. An agenda is prepared and distributed to members prior to the meeting date. The standard agenda will include the following items: Introductions Review of Minutes Old Business Drug Utilization Review (DUR)/Drug Utilization Evaluation (DUE) Formulary Review Treatment Authorization Protocols Policy and Procedure Review Unfinished or tabled business will be carried to the agenda of the following meeting. Major Responsibilities The Chief Medical Officer: Serves as P&T Committee co-chairperson. Reports P&T Committee activities to the Quality Improvement Committee and to the Board of Directors. Oversees the implementation of the Quality Improvement Plan and Utilization Management Plans as they relate to pharmacy services. The Director of Pharmacy Services: Researches current resources to recommend additions or deletions to Community Health Group formularies for Committee review and approval. Develops mechanisms to collect, store, and report utilization data. Conducts drug utilization studies. Researches current resources to develop and recommend prior authorization criteria for Committee review and approval. Disseminates pertinent Committee decisions, recommendations, and actions to Community Health Group s providers, pharmacists and members. Ensures that pharmacy services policies and benefits management is consistent with overall health care plan benefits interpretation. Ensures that the process of technology assessment, as it relates to drug therapy, is consistent with Community Health Group's overall technology assessment policies and process. Develops, implements, revises, and maintains pharmaceutical management policies and procedures. Conflicts of Interest Health care providers who participate on the P & T Committee agree that his/her participation, decisionmaking, and/or voting relating to the Committee s activities are unhindered by any fiscal or administrative constraints, arising from Community Health Group, any entity contracting or doing business with Community Health Group, or any pharmaceutical or medical supply or device researcher, manufacturer, distributor, or seller. Committee members agree to make fair and impartial recommendations, decisions, and or votes concerning issues before the Committee. In the event of a potential or actual conflict of interest, the involved Committee member may participate in the QIP

83 Committee s discussion, but will abstain from casting an official vote on issues to which the potential or actual conflict of interest may be relevant. (See Appendix C). Confidentiality Sensitive, confidential, and proprietary information is often discussed during P & T Committee meetings. Members and guests are required to sign a Confidentiality Statement prior to participating in Committee meetings and agree to the standards of confidentiality set forth in Community Health Group s peer review process, as described in Community Health Group s Quality Improvement Plan. (See Appendix C) Decisions Made Without Regard to Financial Incentives Community Health Group distributes to all its members, practitioners, providers, and employees who make UM decisions a statement describing its policy on financial incentives and requires practitioners, providers and staff who make utilization-related decisions and those who supervise them to sign a document acknowledging that they have received the statement. This statement affirms that: UM decision making is based only on appropriateness of care and service and existence of coverage Community Health Group does not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service care, i.e., compensation is not related to review decisions Financial incentives for UM decision-makers do not encourage decisions that result in underutilization. Committee Functions Serve in an advisory capacity in all matters pertaining to the use of drugs. Serve in an advisory capacity in the selection or choice of drugs that meet the most effective therapeutic quality standards. Evaluate objectively, clinical data regarding new drugs or agents proposed for use. Recommend additions and deletions from the list of drugs accepted for use by Community Health Group Members (Drug Formularies except Medicare). Establish or plan suitable educational programs on patient matters related to drugs and their use. Recommend policies regarding the safe use of drugs among contracted facilities. Monitor compliance with established Community Health Group policies regarding the distribution, storage, administration and use of drugs. Maintain an on-going DUR/DUE program to evaluate the quality of drug use and patient outcomes, including the oversight of point of dispensing identification and classification (by severity) of drugdrug interactions and notification to dispensing providers (at the point of dispensing) of specific interactions when they meet CHG s established severity threshold. Establish or plan suitable educational programs for Community Health Group Members on the use of drugs, including Community Health Group s Medication Therapy Management Program (MTMP). Initiate corrective action on findings of outside review committees and audits in areas pertaining to the use of drugs. Review use and appropriateness of non-formulary medications. Review questionable therapies or issues and make recommendations. Develop, review and evaluate authorization/review criteria. 77 QIP 2015

84 Annually, evaluate and approve P&T program description. Assist, advise, and support (upon request and when applicable) Community Health Group s Antifraud Committee. Formulary Review Process and Criteria Community Health Group maintains a closed drug formulary for its Medi-Cal line of business. Community Health Group has adopted its PBM s Medicare Advantage formulary and associated prior authorization criteria, step edits and step criteria, and quantity limits. The maintenance and updating of the Medicare formulary has been delegated to the PBM based on Medicare requirements and guidelines. Therefore, Community Health Group s P&T Committee is not charged with the review and maintenance of the formulary but rather the oversight of the delegation for the formulary review process. The scope of coverage, classes of pharmaceuticals, co-payment policies, exclusions and limitations, policies and procedures may be affected by contractual and regulatory requirements. Community Health Group s Medi-Cal Formulary is influenced by the state of California s Medi-Cal List of Contracted Drugs. The P & T Committee reviews additions, deletions, and changes to the Medi-Cal List of Contracted Drugs as they are announced in the Medi-Cal Provider Bulletins. The Committee may elect to adopt, modify, or reject the actions taken by the state. The PBM s formulary review documents, actions, and recommendations are reviewed by the P & T Committee. The Committee reviews the PBM s actions and recommendations for relevance to Community Health Group s membership, practitioner practice patterns, and contracts. Process (Medi-Cal & CMC) As a standing item in the Formulary Review section in each agenda, the P & T Committee reviews the changes made to the Medi-Cal List of Contract Drugs and its PBM s P & T Committee actions since the previous meeting, as well as Medicare Part D formulary changes. The P & T Committee performs a complete, annual review of each formulary. The Committee will review new drug products after the product has been available in the United States for a minimum of six (6) months except when: The new drug provides a significant therapeutic gain over existing products, or The drug belongs to a new therapeutic entity in which there are no current products in its class or disease state category, or When added to the Medi-Cal List of Contract Drugs. New drug products will be reviewed upon receipt of written request from a participating practitioner or by request of a committee member. New drug products will not be reviewed when solely requested by the pharmaceutical industry or if the provider request is submitted or substantially found to be originated by the pharmaceutical industry. Drug review by therapeutic class: Periodic drug class therapeutic reviews are conducted by the PBM s P & T Committee. CHG s P & T Committee reviews the clinical evidence included in the monographs, proposed prior authorization or medical exception criteria, and formulary placement, including preferred status QIP

85 and any utilization measures such as step protocols, quantity limits, prior authorization requirements, and exclusions or limitations. CHG s P & T Committee considers the actions of the PBM in maintaining and updating the formularies. Development of Review Material for Formulary Consideration (Medi-Cal Only) Monographs of drugs or drug classes and other material used in considering formulary decisions are compiled prior to review and include but are not limited to the following: American Medical Association specialty society guidelines. Governmental agencies - e.g., Centers for Disease Control, Federal Drug Administration, Agency for Healthcare Research and Quality, National Institute of Health. Local and Regional agencies, e.g., State and County Health Department Community Based Organizations, e.g., American Diabetes Association, American Lung Association. Clinical data published in peer-reviewed journals. Pharmacy Benefits Manager (PBM) drug monographs and comparative pricing guidelines. Selection Criteria for Formulary Drug Status (Medi-Cal Only) Drugs presented to the Committee for consideration will be reviewed using the following criteria: Safety Efficacy: the potential effects of treatment under optimal circumstances Effectiveness: the actual effects of treatment under real life conditions Cost and outcome modeling: potential health outcomes and resulting total cost of drug and medical care; potential savings available Relevant benefits of current formulary alternative of similar use Condition of potential duplication of similar drugs currently on formulary Any restrictions that should be delineated to assure safe, effective, or proper use of the drug Selection Criteria for Preferred Formulary Drug Status (Medi-Cal Only) Drugs that have the same generic names or are in the same therapeutic class and have very similar therapeutic activity may qualify for preferred formulary status. These preferred drugs should offer equal safety and efficacy as well as increased cost effectiveness over drugs with similar therapeutic benefit. Selection Criteria for Generic Substitution (Medi-Cal Only) Drugs that have FDA Orange Book evaluations with the equivalency rating of AB may be proposed for generic substitution. Community Health Group uses its PBM s Maximum Allowable Cost (MAC) lists. The PBM s MAC criteria are: A multi-source product manufactured by at least two (2) nationally marketed companies. There must be significant price spread between the brand and the generic product. At least two (2) of the generic manufacturers must have an AB rating. The PBM s P&T Committee must approve product for generic substitution. Certain drug products with complex pharmacokinetics, dosage forms, narrow therapeutic efficacy or where blood level maintenance is crucial will not be subject to substitution. Such a list of products will be published in the current version of Community Health Group s formularies. If a member or physician requests a brand name product in lieu of an approved generic, a request for coverage may be made using the medical exception process. Depending on the benefit 79 QIP 2015

86 structure, the member may be required to pay the difference in cost between the brand and the generic. Therapeutic Interchange (Medi-Cal & CMC) The practice of therapeutic interchange (substituting different drugs or different formulations of the same drug from the same class with very similar therapeutic outcomes) is not incorporated in any of Community Health Group s policies and procedures. Selection of Drugs for Step Therapy (Medi-Cal Only) Drugs may be selected for step therapy within a particular medical condition where there is a logical succession of drugs to be used. In such a succession of agents, where there is equal safety and efficacy, the most cost effective preferred agent might be suggested first. If the first drug is not therapeutically effective or if the patient experiences adverse effects, a second line agent may be recommended and so forth. The step therapy protocols for a given drug shall be determined by the formulary review process and/or the prior authorization criteria review process. The step therapy procedure is automated by computer review of a member s drug history or implemented within prior authorization review criteria. Claims that are not automatically approved will be processed by the standard Medical Exception Request process. Dispensing Limitations, Co-pays, and Restrictions (Medi-Cal & CMC) The quantity of units dispensed and co-payment policies (how much and when they apply) will be a function of the defined benefit structure. Certain drugs may be restricted to a limited number of doses or refills based on such criteria as: potential overdose hazard, abuse potential, approximation of usual doses per month, compliance with follow-up (e.g., regular laboratory tests to be drawn prior to continuation of therapy), potential for fraudulent and/or irregular billing, and contractual and regulatory guidelines. The exclusion of various drug classes (e.g., over the counter medications (OTC), experimental drugs, drugs used for cosmetic purposes, injectable drugs, weight loss products) is a function of the defined benefit structure. Distribution of Formulary and Communication of Pharmaceutical Management Procedures Formulary Distribution Current versions of Community Health Group s formularies are posted on Community Health Group s web site and are accessible to both members and practitioners. Community Health Group s pharmaceutical management procedures are included within the formulary as well as in the Member Guide (Combined Evidence of Coverage and Disclosure Form) and Provider Manual. Members, prescribers, and pharmacies may receive a printed copy of the formulary(ies) upon request. QIP

87 Notification of Formulary Changes Formulary changes generally occur after each scheduled P&T Committee meeting. Any changes to the pharmaceutical management procedures are also posted on Community Health Group s web site. Written information of the availability of the information on the web site will be communicated to participating practitioners through a faxed Provider Alert or provider newsletter article. Practitioners and pharmacists may request a printed copy of the information posted on the web upon request. Any potential changes to the Medicare formulary will follow established Centers for Medicare and Medicaid (CMS) standards. Changes are posted on web site 60 days in advance of the effective date of the change. Members also receive a formulary change notice with their explanation of benefits (EOB). Medical Exception Request Review Criteria and Process (Medi-Cal) Medical Exception Review Criteria Community Health Group develops its own medical exception review criteria and/or adopts its PBM s criteria. The P&T Committee reviews and approves each set of criteria (both Community Health Groupdeveloped and PBM-developed criteria) prior to use and performs an annual review of all criteria. When applying the criteria in a review of a request, Community Health Group s criteria are applied when they exist. When Community Health Group-developed criteria does not exist, the PBM s criteria will be applied. Development Process The process for developing internal medical exception review criteria is as follows: Based on research of the reference material cited above in the formulary review process, a draft of the medical review criteria is formulated by the Director of Pharmacy Services with input from the Chief Medical Officer and a third party specialty practitioner when appropriate. The third party specialty practitioner is an individual selected on the basis of board certification in the applicable field and a current active practice in the specialty of his/her board certification conducted for the past two years. The Director of Pharmacy Services is responsible for presenting the draft criteria to the P & T Committee for review, recommendations, and ultimately, approval. The draft criteria may be distributed to all or a subset of practitioners for additional review and input. Practitioners are notified of the availability of criteria. Specific criteria are available upon request The approved criteria are distributed to the PBM for application upon medical exception requests. Application of Criteria During the review process, additional material, such as a variety of peer-reviewed criteria, guidelines and reference tools may be used to determine medical appropriateness. Criteria is also applied on a case-by-case basis and consideration will be given to an individual s age, comorbidities, complications, progress of treatment, psychosocial situation, home environment, issues relating to compliance, as well as the capabilities of Community Health Group s health care delivery system. 81 QIP 2015

88 Medical Exception Review Process The prescriber, pharmacy provider, and/or member may request non-formulary drugs and supplies (when included as part of the benefit). Prior authorization requests may be made by faxing a completed Medication Request Form (MRF) to the PBM. Requests may also be processed over the telephone by calling the PBM. The following general criteria are used to evaluate requests for non-formulary drugs: The member s benefit provisions (e.g., Medi-Cal coverage criteria). The use of formulary drug(s) is/are contraindicated in the patient. The patient has failed an appropriate trial of formulary drugs or related agents. The choices available on the drug formulary are not suited for the present patient care need and/or the requested drug is required for patient safety. The use of a formulary drug may exacerbate an underlying condition that would be detrimental to patient care. The patient has been maintained on a requested drug by Community Health Group or previous insurance immediately prior to enrollment date (documentation required). The MRF, when legibly and completely filled out, should provide most of the medical necessity information required to apply the criteria and to make a determination. The pharmacy provider may obtain this information from the prescribing physician or forward the form to the prescribing physician for completion. All requests containing completed information are processed within 24 hours or one business day. Reviews of requests may be expedited to address the needs of a member s health condition. A determination may be deferred pending additional medical documentation for up to 28 calendar days from the date of the initial request. If the requested documentation is not provided within this time frame, the request will be denied. If the PBM cannot make a determination based on the information provided and/or the request does not meet the criteria established by the P & T Committee, the request will be forwarded to Community Health Group for a secondary review by a licensed physician or pharmacist. Only a licensed physician or registered pharmacist may render a decision to deny a request based on medical necessity, provided that such determinations are made under the auspices of and pursuant to criteria established by the Chief Medical Officer, in collaboration with the P & T Committee. If Community Health Group does not approve the request, the member and prescriber will be notified in writing. A reason for the denial of the non-formulary request and notification of alternative drugs or treatments offered by Community Health Group will be provided in the notice. The notice will also indicate that the member may file appeal or file a grievance with Community Health Group if the member does not agree with the denial and how to file an appeal or grievance. Pharmaceutical Patient Safety Community Health Group s pharmaceutical quality improvement process includes measures and reporting systems to address the identification and reduction of medication errors and adverse drug interactions. The PBM s utilization review (DUR) edits provide on-line messaging to dispensing pharmacists. The PBM identifies drug-drug interactions based on three severity levels supported by nationally recognized references (e.g., First Data Bank, NDDF Plus, National Drug Data File). Eight (8) online DUR edits are used and send a message to the dispensing pharmacist when triggered : Drug Interaction Drug dosage QIP

89 Ingredient duplication Age precaution Pregnancy precaution Gender conflict Therapeutic duplication Late refill There is also a Sound Alike drug edit to help prevent confusion between similar drug names. A message back to the dispensing pharmacist prompts the pharmacist to check the drug with the name of the drug with which it is most commonly mistaken. The PBM identifies and notifies CHG of members and prescribers affected by a Class II recall or voluntary drug withdrawals from the market for safety reasons. CHG uses these reports to notify affected physicians and members within 30 calendar days of the FDA notification. An expedited process is followed for prompt identification and notification of members and prescribing practitioners affected by a Class I recall. When the FDA recalls a drug, the product is immediately removed from CHG s formularies and active prior authorizations are terminated. Community Health Group also conducts retrospective drug utilization of pharmacy claims and other records, through computerized drug claims processing and information retrieval systems to identify patterns of inappropriate or medically unnecessary care among members or associated with specific drugs or groups of drugs. Community Health Group, through its contracted PBM pharmacy network, ensures that patient counseling is offered to members, when appropriate and that network pharmacies implement a method for maintaining up-to-date member information, such as but not limited to, member demographic information and allergy information (food and drug). Over-/Under-utilization Monitoring and Prevention Community Health Group monitors and implements processes to prevent over-utilization and underutilization of prescribed medications, including but not limited to the following elements: Compliance programs designated to improve adherence/persistency with appropriate medication regimens; Monitoring procedures to discourage over-utilization through multiple prescribers or multiple pharmacies; Quantity versus time edits; Early refill edits. Delegation Oversight Community Health Group delegates some of its pharmaceutical management activities to a PBM. A delegated services agreement, signed by both parties, describes the scope of the delegation. Various aspects of the PBM s performance are evaluated: Customer Service Feedback on the PBM s customer service is continuously solicited from pharmacies and practitioners through the Pharmacy Feedback Form. The form is included within Community Health Group s 83 QIP 2015

90 (CHG s) formulary and is periodically distributed via fax and during meetings with practitioners and pharmacies. Periodic surveys of pharmacies are planned to solicit more specific feedback regarding the PBM s performance. The PBM surveys its clients every four months regarding all aspects of its services (e.g., customer service, clinical programs, information technology, and account management). CHG provides regular feedback through these surveys as well as on a case-by-case basis, when necessary. Performance guarantees regarding targeted service end-points are built into the contract with the PBM. Accuracy in Processing and Reporting Key pharmacy performance indicators are monitored via scheduled reports (monthly and/or quarterly). Indicators are trended and compared with industry benchmarks. Any aberrance is further evaluated. Various reports are cross-checked against each other for consistency and accuracy. Prior Authorization Processing A sample of prior authorization requests that are processed by the PBM are evaluated on an ongoing basis for adherence to established timeliness standards, application of established procedures, and accuracy in the application of protocols. The PBM audits its compliance with established timeliness standards and shares audit reports with CHG. Pharmacy Provider Qualifications The PBM maintains a qualified pharmacy network as designated by Community Health Group. The PBM: o Obtains pharmacy permits, Drug Enforcement Agency (DEA) registrations, and respective expiration dates when pharmacies are added to the network. o Monitors to ensure that pharmacies are in good standing with the Department of Health Care Services and Centers for Medicare and Medicaid Services, including the monitoring of the Medi-Cal and Office of Inspector General suspended provider listing. o Maintains a system to verify that pharmacy permits and DEA registrations are kept current within its records. o Maintains a process for updating and maintaining a current network listing. o Provides Community Health Group with reports to indicate that it is monitoring the current status of participating pharmacies permit and DEA registration. Medicare Advantage Prescription Drug Plan Qualifications The PBM s formulary review process and Pharmacy and Therapeutics Committee roster are reviewed to ensure that the prevailing Medicare Advantage Prescription Drug Plan (MA-PD) requirements are met. Community Health Group reviews that the PBM ensures, through its contracted pharmacy network, that patient counseling is offered to members, when appropriate, and that network pharmacies implement a method for maintaining up-to-date member information, such as but not limited to, member demographic information and allergy information (food and drug). Delegated Services Agreement A delegated services agreement between CHG and its PBM addresses the annual review of the PBM s pharmaceutical management policies and procedures by CHG. QIP

91 The written delegation agreement: Is mutually agreed upon Describes the responsibilities of CHG and the PBM Describes the delegated activities Requires at least semiannual reporting to CHG Describes the process by which CHG evaluates the PBM s performance Describes the remedies, including revocation of the delegation, available to CHG if the PBM does not fulfill its obligations The delegation document also includes the following provisions regarding the use of protected health information (PHI): A list of the allowed uses of PHI A description of PBM safeguards to protect the information from inappropriate use or further disclosure A stipulation that the PBM will ensure that subdelegates (if applicable) have similar safeguards A stipulation that the PBM will provide individuals with access to their PHI A stipulation that the PBM will inform CHG if inappropriate uses of the information occur A stipulation that the delegate will ensure that PHI is returned, destroyed or protected if the delegation agreement ends. 85 QIP 2015

92 QIP Quality Improvement Program Description