GOALS. I. Monitoring the quality of health care for safety, effectiveness and efficiency and seek opportunities for improvement

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1 MUTUAL OF OMAHA INSURANCE COMPANY UNITED OF OMAHA LIFE INSURANCE COMPANY PPO & MANAGED INDEMNITY MEDICAL & DENTAL PLANS EXCLUSIVE HEALTHCARE, INC QUALITY IMPROVEMENT PROGRAM The Quality Improvement (QI) Program illustrates the Company s commitment to provide comprehensive medical care that maintains high standards. It creates a framework to monitor, evaluate, and maintain the care given. The program will promote desired outcomes and improve the process of care delivery. It will provide an ongoing evaluation process that lends itself to improving or correcting identified shortcomings or improper utilization. The QI Program will focus on the application of preventive health services. Standards will be set and monitoring will be done to insure these services remain a focus. Preventive health care remains the key to the attainment of both a cost effective health plan and improved member health and satisfaction. In addition, the Company will work with National, State and local public health initiatives to promote the health of members. The QI Program will insure that the quality of services supports the maintenance of member s rights and exceeds time service standards in all management functions. In addition, the services provided will have sufficient breadth and range to meet the member s and network s requirements. The QI Program will attain an understanding of the populations served, in terms of age groups, disease categories and special risk status through monitoring and the evaluation processes. These processes will also reflect important aspects of care and service including behavioral health, high-volume and high-risk services and the care of acute and chronic conditions. GOALS The QI Program is structured to achieve its purpose through the attainment of four goals, each addressing a component of care. The goals include: I. Monitoring the quality of health care for safety, effectiveness and efficiency and seek opportunities for improvement II. III. IV. Insuring that members are aware of their rights and responsibilities for their health care, to monitor satisfaction with the Plan, and to promote access to care Insuring members have access to qualified providers Utilizing the Total Quality Improvement (TQI) Process to insure goal attainment OBJECTIVES The objectives of the QI program are determined by the goals as previously listed. I. To monitor the quality of health care for safety, effectiveness, and efficiency, and seek opportunities for improvement 1

2 A. Develop and implement policies, which increase the likelihood of desired health outcomes for individuals and populations and maintain regular evaluations of those policies to insure they are current and appropriate B. Adopt and use practice guidelines or explicit criteria that are based on reasonable scientific evidence and are reviewed by network providers C. Consider and support National, State and local public health goals and initiatives when developing quality improvement activities for members D. Identify clinical issues that impact the health status of all members while focusing on the important aspects of care and services. This will include: High volume, high risk services Acute and chronic conditions Behavioral Health services E. Monitor and evaluate the effectiveness of health management with emphasis on: Over-utilization Under-utilization Risk prevention Preventive health High risk case management F. Promote and improve enrollee safety, as required to meet state specific requirements by monitoring sentinel events II. To insure that members are aware of their rights and responsibilities for their health care, to monitor satisfaction with the Plan, and to promote access to care A. Inform members of their rights and responsibilities B. Offer members the opportunity to offer suggestions for changes, inform them of QI study results, and monitor member complaints and QI study results for opportunities C. Maintain and improve member satisfaction through continuous analysis of QI data D. Facilitate health promotion E. Facilitate the resolution of complaints and grievances F. Protect the confidentiality of member demographic and medical information III. To insure members have access to qualified providers A. Define criteria to identify panels of qualified, cooperative and accessible medical care and behavioral health providers by establishing and maintaining a network of qualified providers based on specific participation requirements implemented through a formalized credentialing and recredentialing process 2

3 B. Insure that the qualifications and performance of physicians and other defined health care professionals providing care are regularly evaluated C. Involve participating providers, including behavioral health and dental, in the process of improving patient care and services: Communicate QI information and data to network providers, as appropriate, and continuously seek their input into program enhancement Identify the needs and expectations of providers and evaluate Plan performance relative to these needs and expectations Insure all provider contracts have a provision for cooperation with the QI program IV. To utilize the Total Quality Improvement (TQI) Process to insure goal attainment A. Utilize QI measurements, data collection, and analysis to monitor and track QI, to include systematic follow-up of actions to assess effectiveness: Maintain an accurate and current data information system for trending, problem analysis and other QI processes Continually monitor the system to detect trends in quality of care and service Insure the resolution of quality issues through QI activities Establish, implement and monitor corrective action plans when deficiencies are identified Integrate interdepartmental QI activities B. Utilize quality indicators that are objective, measurable, and based on current knowledge and clinical experience to monitor and evaluate each important aspect of care and service identified: Determine performance goals and/or a benchmarking process for each indicator Utilize appropriate methods and frequency of data collection for each indicator C. Insure involvement of all levels of management in QI activities Periodic reporting of QI activities to the Board of Directors, appropriate governing authority or its designate Review QI Program and Work Plan with the Board of Directors or its designee STRUCTURE As the TQI process expands to other Company departments, the QI Program will also grow. Currently the following structures are in place: I. Personnel/Departments A. Senior VP of Managed Care Programs: Is a member of Quality Improvement Medical Advisory Committee (QI- MAC) and Quality Improvement Oversight Committee (QIOC) 3

4 Is responsible for insuring QI has the necessary staff and resources to support the day to day operations of the QI Program B. Senior VP & Medical Director of Medical Management: Chairs QIOC Is responsible for Medical Management (MM) and has oversight of the QI Program Is responsible for reporting MM and QI activities to the appropriate Board or governing body Provides guidance and is responsible for all clinical aspects of the MM and QI Program Supports MM and QI in preparing policies and procedures necessary to implement the MM Program and Work Plans Works with providers when MM or QI issues are identified Has periodic consultation with practitioners in the field Insures that continuing education courses are provided for Plan professional staff C. 1 st VP of Care Services: Is a member of QIOC and QI-MAC Is responsible for the daily operations of the Care Services department Provides guidance and direction to the Care Services programs and assures compliance with State and Federal regulations and URAC standards Assure staff development and continuing education for professional staff Assures that adequate measures are in place to monitor the quality of services provided D. 1 st VP of IFS Compliance: Is a member of QIOC Is responsible for reporting on Individual health product claim activities, time service and quality Is responsible for IFS compliance with state and federal regulations E. 1 st VP of GBS Claims, Customer Service & Compliance: Is a member of QIOC Responsible for reporting on group claims processing activities, time service and quality Responsible for insuring group claims compliance with state and federal regulations Responsible for group customer service through call centers and for reporting activities and statistics Is responsible for GBS compliance with state and federal regulations Insures continuing education and updates on legislative issues F. VP & Medical Director (s): Chairs or is a member of the QIC, QI-MAC, P&T, and Corporate Grievance, Criteria/TAC, Behavioral Health and Credentialing Committees Insures that results of QI investigations obtain physician review to determine if quality of care issues exist 4

5 Works with providers when MM or QI issues are identified Assists with study development, data analysis and preliminary development of action plans Supports MM & QI in preparing the policies and procedures necessary to implement the MM and QI Programs and Work Plan Insures annual review of medical necessity criteria, medical policy statements and preventive health guidelines Coordinates and completes data analysis on the Congestive Heart Failure (CHF), Asthma, and Diabetes Disease State Management (DSM) Programs Oversees EAP services G. QI/Compliance Department: Provides coordination and oversight for the development and implementation of the QI Program that promotes objective systematic monitoring and evaluation of consumer and client service and health care services Provides coordination and oversight for the development and quarterly updates of the QI Work Plan and quarterly reports that monitor progress in meeting goals Provides coordination and oversight for the development of the annual QI Evaluation that evaluates the effectiveness of the QI Program Provides coordination and oversight to insure compliance is maintained with external QI regulations and programs (URAC, State and Federal programs and Departments of Insurance) Identifies and develops selected clinical studies, completes the data collection, analyzes the results, and presents the findings to QI-MAC and QIC for corrective action plan development, as required Completes quality audits on physicians medical records to assess compliance with the Medical Record and Preventive Health guidelines Utilizes clinical staff for medical reviews and data collection for QI initiatives Investigates potential MM and/or QI quality of care concerns and prepares for peer review, if required Provides mechanisms to respond on an urgent basis to situations that pose an immediate threat to the health and safety of members, sentinel event reviews, assessment of causes for utilization pattern variations, auditing of case files and referrals to QI-MAC for any potential quality of care issues Coordinates annual member satisfaction survey activities, including vendor contracting, analysis of results and implementation of the corrective action plan, as required Coordinates and assists with identification of topics for member and provider Plan communications Coordinates the reporting of QI and MM activities to QI-MAC, QIC and QIOC Coordinates the annual review of the MM policies and procedures QI department staff members will be members of the QIOC, QIC and QI-MAC. H. Care Services Department: 5

6 Develops and coordinates the implementation and evaluation, annually, of the Medical Management Program Maintains compliance with external MM regulations and programs (URAC, State and Federal programs and Departments of Insurance (DOI) Monitors phone access to meet identified service standards Utilizes professional staff for medical necessity reviews and case management Completes silent monitoring to insure quality Provides case management to promote quality continuity and cost-effective care Completes annual MM studies with analysis and development of action plans when opportunities are identified Identifies and refers quality issues to QI for investigation Monitors utilization of inpatient and outpatient services Identifies and coordinates risk management Arranges for new employee training and updates/refreshers for current staff on the systems and processes of medical management Care Services staff members will be members of the QIC, QI-MAC, P & T Committee, Corporate Grievance Committee, Criteria/TAC and Behavioral Health Committees. I. Managed Care Services: Coordinates the resolution of all member and provider appeals, complaints and grievances Logs and monitors time service for medical necessity appeal resolution Investigates all Presidential and DOI complaints Manages and tracks all PPO MM appeals, Medical Claim Review (MCR) second level appeals, PPO operation member complaints and all HMO MM and MRD appeals, complaints and grievances Investigates pertinent PCP change requests and physicians request to terminate members from their panel Provides data on physician quality indicators to the Credentialing committee Compiles all information for credentialing/recredentialing -- primary verification as indicated for education, board eligibility/certification, malpractice history, quality/access issues, MM issues and satisfaction information, as available and applicable for each state Identifies provider issues, develops and implements a corrective action plan and monitors results Insures annual evaluation of the credentialing/recredentialing policies and procedures Monitors provider billing practices through claim reviews Provides oversight of delegated Credentialing/Recredentialing Managed Care Services staff members will be members of the QIC and the Credentialing and Behavioral Health Committees. J. Pharmaceutical Department: Gathers medical information for drug reviews 6

7 Monitors time service for drug reviews Follows compliance regulations regarding notification of members and providers of certification decisions Follows compliance regulations regarding documentation of clinical information pertaining to drug reviews Utilizes licensed health care professionals to conduct reviews for prior authorization of applicable medications Provides response to internal inquiries regarding pharmacy benefits Serves as a drug information resource to internal medical staff Provides service to the Internal Audit Department to support investigations into controlled substance abuse Oversees management of the formulary Provides reporting to internal and external customers regarding prescription trends Updates pharmaceutical criteria following current medical literature and accepted medical practice A Pharmacy department staff member will be a member of the QIC and Pharmacy and Therapeutics Committees. K. Contracting/Provider Relations staff (National PPO & Midwest Region): Initiates and maintains provider contracts so they meet federal, state and accrediting bodies regulations with respect to QI, MM and credentialing Contracts with networks and/or direct contracts for all providers and services Insures that contract language supports the QI and Medical Management Programs Coordinates annual provider satisfaction surveys, analysis of results, and corrective action plan development as applicable Is responsible for the Provider Digest and other provider communications related to drug, QI or other educational purposes Monitors access and availability of services Assists members/providers with coding/claims payment issues, as appropriate Resolves member concerns related to provider access and billing issues Assists with provider information regarding our website A National PPO and/or Midwest Region Contracting/Provider Relations staff member will be a member of the QIC and the Credentialing Committee. L. Provider Repository, Directories and Communication: Maintain/obtain provider data for directories and the website Produce provider directories Maintain database of employer group and internal customers Fulfill provider directory requests Coordinate/oversee provider search and Directories-on-Demand website Respond to RFPs and RFIs Provide GeoAccess Accessibility and other internal provider reports 7

8 A Provider Repository, Directories and Communication staff member will be a member of the QIC. M. Data Management: Provide membership and member month information Report preparation and report request used to investigate and review claim issues and questions Coordinate the preparation and review of HEDIS and CAHPs data Preparation of the Days/1000 report used to track and review inpatient utilization Report preparation used to verify and answer questions highlighted on the provider profiler A data management staff member will be a member of the QIC. N. GBS Claims and Customer Service Department: Adjudicates claims according to benefits and contracts Monitors and maintains claims processing time service Assists in the resolution of member and provider complaints/concerns, as appropriate Refers appropriate appeals to the Appeals Department Maintains established service standards and quality monitoring for telephone access Assists in the resolution of member/provider concerns and claims payment issues, as appropriate Provides benefits and Plan information to members and providers A GBS Claims Compliance staff member will be a member of the QIC. O. Individual - Claims/Customer Service/Corporate Compliance - Consumer Relations IFS - Compliance/Underwriting/POS: Investigates and resolves all member/provider non-medical necessity appeals, complaints and/or grievances Works in conjunction with QI to insure compliance is maintained with external QI regulations Resolves Presidential, Congressional and DOI complaints Logs and monitors time service for non-medical necessity appeal, complaint and/or grievance resolution Pays claims according to benefits and contracts Monitors and maintains claims processing time service Assists members/providers with claims payment issues, as appropriate Assists in the resolution of member concerns, as appropriate Refers appropriate appeals to the Appeals department Issue policies or certificates to new customers An Individual Financial Services Compliance staff member will be a member of the QIC. P. GBS Claims Compliance Department: 8

9 Works in conjunction with QI to insure compliance is maintained with external QI regulations Resolves all Group Benefit services (GBS) Presidential, Congressional, DOI, media and other types of elevated complaints Monitors time service for appeals, complaints and/or grievance resolution Monitors and ensures compliance of state and federal laws and regulations by the Claims areas Write procedures for the claims areas Assists the law department in matters of litigation related to GBS Assists IDS with claims issues in preparing and during Market Conduct Examinations Completes annual/quarterly claims and grievance reports for State Insurance Departments Completes state surveys for GBS A GBS Claims Compliance staff member will be a member of the QIC. Q. Group Product Compliance: Coordinates with QI and MM to insure compliance is maintained with state and federal regulations Responsible for filing procedural changes and/or updates with appropriate state regulatory agencies Coordinates all Market Conduct Examination activities for GBS Coordinates all utilization review license filings A Group Product Compliance staff member will be a member of the QIC. R. Other resources include Administrative support to: Assists with typing, copying, filing, faxing and telephone support Assists with meeting preparations Records minutes for the Plan s committees Assists with mailings II. Committee Structure The Board of Directors for the Company s have delegated the authority and responsibility for QI in all managed care product lines to the QIOC. A. The QIOC will: Be chaired by the Senior VP & Medical Director of Medical Management Include at a minimum: the Senior VP of Managed Care Programs, 1 st VP of Care Services, 1 st VP of IFS Compliance, 1 st VP of GBS Customer Service, and QI/Compliance Manager. Meet at least quarterly The QIOC responsibilities include: Oversight of QIC and all QIC subcommittees Review and approve monthly QIC minutes Review and approve the annual QI Program and MM Program 9

10 Review and approve the quarterly QI Work Plan and Quarterly Reports Review and approve the annual QI and MM Evaluation Review and provide oversight, guidance and recommendations for corrective action plans for QI studies and activities Review network providers disciplinary actions as needed for credentialing or recredentialing B. The Plan s committee responsible for oversight of the quality improvement program and activities is the Quality Improvement Committee (QIC). The QIC will: Be chaired by VP & Medical Director of Medical Management Include a staff member from the following departments: additional VP & Medical Director of Medical Management, QI/Compliance Manger, QI Staff member, Care Services (2), Managed Care Services, Pharmacy, Midwest Provider Contracting, National PPO Provider Contracting, Provider Repository, Directories and Communication, Data Management, Group Claims/Customer Service, GBS Compliance and IFS Compliance. Meet monthly The QIC responsibilities include: Coordinate the reporting of QI documents and activities to the QIOC Oversee and coordinate the QI activities for each department included in the QI Program Review and approve the annual QI Program and MM Program Maintain approved minutes of all committee meetings Review and provide oversight, guidance and recommendations for corrective action plans for QI studies and activities Approve the QI studies and activities to undertake Monitor progress in meeting quality improvement goals by reviewing the quarterly QI Work Plan and Quarterly Reports Review and approve the annual QI and MM Program Evaluation to evaluate the effectiveness of the programs Review and approve QI and MM policies and procedures C. Subcommittees: 1. QI-MAC will: Be chaired by VP & Medical Director of Medical Management Include at a minimum: additional VP & Medical Director of Medical Management, Senior VP of Managed Care Programs, QI/Compliance Manager, 1 st VP of Care Services, QI staff member and a minimum of six network physicians that include both PCPs and specialists, as appropriate. Meet at least quarterly QI-MAC responsibilities include: Review and approve the annual QI Program and MM Program Review and provide oversight, guidance and recommendations for corrective action plans for QI studies and activities Approve the QI studies and activities to undertake 10

11 Monitor progress in meeting quality improvement goals by reviewing the quarterly QI Work Plan and Quarterly Reports Review and approve the annual QI and MM Program Evaluation to evaluate the effectiveness of the programs Peer Review on identified cases for potential quality issues 2. Credentialing Committee will: Be chaired by VP & Medical Director of Medical Management Include at a minimum a Provider Contracting Manager, Managed Care Services Manager, and a minimum of five network physicians Meet on a monthly basis Credentialing committee responsibilities include: Review all providers to be credentialed or recredentialed with respect to their: Valid license to practice Clinical privileges Valid unrestricted DEA or CDS certification, State and Federal Board eligibility status or education Work history for five years Insurance: malpractice and general NPDB query State Medical Board query Identified Medicare/Medicaid sanctions Signed, completed application Malpractice history Identified QI issues (recredentialing only) Review all providers recommended for termination by the QI-MAC Be informed of all providers recommended for termination due to Plan decisions Review the credentialing/recredentialing policies and procedures annually 3. Pharmacy & Therapeutics Committee will: Be chaired by the Manager of Clinical Pharmacy Operations Include at a minimum: a Company Pharmacist, VP & Medical Director of Medical Management, Care Services, network pharmacists and network physicians Meet a minimum of quarterly Pharmacy & Therapeutics Committee responsibilities include: Annually review the Formulary for additions and deletions and review any new drugs that come become FDA approved Annual review/revision of Pharmacy Management policies and procedures Development and annual maintenance of drug review criteria 11

12 Review and determine policy on investigational/experimental pharmaceuticals agents and protocols Investigate and resolve pharmaceutical clinical and service issues Determine annually if any pharmaceutical studies are indicated 4. Corporate Grievance Committee will: Be chaired by the Senior VP of Medical Management Include at a minimum: VP & Medical Director of Medical Management, 1 st VP & Medical Director of Medical Management (actively practicing providers), Care Services Supervisor, Claim(s) representatives, and other ad-hoc staff and/or specialty providers as warranted Meet twice monthly at a minimum, more frequently if needed Corporate Grievance Committee responsibilities include: Serve as the final internal level of review for all medical appeals and complaints unless prohibited by state mandates Provide a forum at which a member or their representative can appeal or present a grievance in person or through other technological communications Review all new medical and pertinent information from providers and members/family and provide a timely response to all interested parties within 48 hours of the decision Report findings to the QI Committees 5. Behavioral Services Committee will: Be chaired by VP & Medical Director of Medical Management Include at a minimum: Care Services Supervisor, Behavioral Health Services staff members, Managed Care Services Manager and Managed Care Services staff member Meet a minimum of quarterly Behavioral Services Committee responsibilities include: Investigate and resolve Behavioral Services clinical and service issues Determine annually if any behavioral service studies are indicated 6. Criteria and Technology Assessment will: Be chaired by VP & Medical Director of Medical Management Include at a minimum: Additional VP & Medical Director of Medical Management, a practicing 1 st VP & Medical Director, Care Services staff member, Training Representative, Company Pharmacist and Criteria/TAC staff representative Criteria and Technology Assessment Committee responsibilities include: Annual review of medical necessity criteria for medical and behavioral health Review, revision and development of medical policy statements for medical and behavioral health 12

13 Review, revision and development of clinical practice and preventive health guidelines for medical and behavioral health QI WORK PLAN & QUARTERLY REPORTS The QI Work Plan and quarterly reports will be developed to implement the objectives of the QI Program. The QI Committees will approve the clinical and service studies to be completed. The QI Work Plan and quarterly reports will be updated quarterly and then reviewed by QI-MAC and QIC. Each will then be reviewed and approved with recommendations by QIOC. ANNUAL EVALUATION The annual QI Program Evaluation will be reviewed by QIC to determine if the objectives were met, what improvements were made and what the goals and objectives should be for the following year. All results of QI initiatives will be reviewed and comparison statistical analysis completed, as appropriate. The QI Committees will insure that any areas of concern are addressed and that the resources provided to QI are adequate to maintain the QI Program and Work Plan. QUALITY IMPROVEMENT PROCESS COMMUNICATION The concepts and philosophy of the QI process are incorporated in to all processes. The concepts are operationalized through the Company s commitment to cultural competency, Values for Success and the Code of Conduct. The policies and procedures reflect the Company s pledge to strive for processes that improve the quality of both care and service. Members and providers may access the QI Program, Member Rights and Responsibilities Statement, Confidentiality Statement, Appeals Process, Provider Access and Availability Guidelines, Preventive Health Guidelines, HEDIS Results, Member Satisfaction Survey Results and Disease Management Program information on the Mutual of Omaha web-site, or call ext for a copy of any of these documents. DELEGATION When processes are delegated, Plan must complete an oversight review and have a delegation contract in place, as required to meet state requirements. The Plan must maintain oversight, communicate the required standards and/or regulations to the delegated entity and the Plan will conduct regular audits to evaluate conformance to the standards/regulations, as required. Review and Approval: QIC Chair Date QIOC Chair Date 13