PRIMARY CARE PROVIDER MANUAL TABLE OF CONTENTS 1
INTRODUCTION 1.1 1.2 1.3 1.4 1.5
2 3
ELIGIBILITY MEMBER SERVICES 3.1 3.2 3.3 3.4 3.5
4
Welcome letter Mission. Goals and Objectives Member Rights and Responsibilities Grievance and Appeal Member Satisfaction Survey
PROVIDER RELATIONS 4.1
5
Disclosure Mission, Goals and Objectives Important Phone Numbers Primary Care Physician’s Role Capitated Services Contracted Health Plans Contracted Providers Specialist X-Ray Laboratory Nursing Home DME Physical Therapy
Provider satisfaction Survey
QUALITY MANAGEMENT PROGRAM 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10
QM Program Access to care and services Medical Office Standard Infection Control OSHA Fire and Earth quake safety Patient Emergency Storage of Medication Reporting abuse Facility Site Review
6
UTILIZATION MANAGEMENT PROGRAM 6.1 6.2 6.3 6.4 6.5 6.6 6.7
7
HEALTH EDUCATION 7.1 7.2 7.3 7.4
8
Program Referral Staying Healthy Assessment Breast feeding program
CULTURE AND LINGUISTIC SERVICES 8.1 8.2 8.3 8.4
9
Program Confidentiality & Conflict of Interest Referral Emergency Services CHDP CCS CPSP
Program Grievance and Appeal Proficiency of Interpreter Language Assistant Program
MEDICAL RECORDS 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8
Initial Health Assessment Preventive Health Care Guideline Medical Record System Test Result Missed Appointment After Hour Calls Advance Directive Medication Error
10
CLAIMS
11
ENCOUNTER DATA
12
FORMS
Accountable Heath Care IPA Provider Policy and Procedures
DISCLOSURE STATEMENT
Accountable Health Care – IPA (AHC-IPA) Primary Care Physician manual is confidential, proprietary information. By accepting this manual, Provider agrees not to disclose such information, to protect and hold the information confidential and to use this manual solely for the purpose set forth. The Provider Manual is reviewed and updated annually. Any revision/updated information will be forwarded to all Accountable Health Care - IPA providers and their Staff. Orientation/training would also be conducted as needed.
MISSION STATEMENT
Accountable Health Care-IPA has a Mission that promotes an organization-wide commitment to quality of care through the involvement of key participants, medical staff and management. This commitment extends to:
Objectively and systematically monitoring and evaluating the quality and appropriateness of patient care and patient services.
Pursuing opportunities for the continuous study and improvement of the processes of providing healthcare services to service patient needs.
Monitoring the competency and professional growth of providers and staff.
Restoring identified problems.
Seizing opportunities to positively impact patient care delivery.
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Accountable Heath Care IPA Provider Policy and Procedures
GOALS AND OBJECTIVES
Ensure member access to primary care and preventive health care services.
Improve member health status, health maintenance, education, preventive care as well as early detection and treatment of diseases/disorders.
Provide member education regarding health plan benefits and use of the health care delivery system.
Maintain continuous quality improvement.
Provide culturally and linguistically appropriate services.
Manage technology effectively, avoid duplication of services, and enable resources to be shifted appropriately from acute and specialty care to primary and preventive care.
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Accountable Heath Care IPA Provider Policy and Procedures
IMPORTANT PHONE NUMBERS Mailing Address: Accountable Health Care - IPA 2525 Cherry Avenue, Suite #225 Signal Hill, CA 90755 Tel: (562) 435-3333 /Fax: (562) 981-7431 Department
Title
Name
Medical Director
George M. Jayatilaka, MD
Associate Medical Director Director
Savitri Krishnamurthy Thai Hoang
Administrator
Tess Martin
Director
Laura Noyes RN
Director
Rhoda Brown
Manager
Mary Ann Guevarra
Supervisor
Robert Flournoy
Supervisor
Joel Dizon
Capitation
Manager
Elsa Lacson
Encounters
Manager
Tess Martin
Quality Management & Health Education Provider Services
Director
Laura Noyes, RN
Manager
Etny Orellana
Marketing & Network Development Credentialing
Director
Edward Martinez,
Manager
Xavier Gooden
Customer Services
Manager
Glenn Gonzalez
Utilization Management (Out Patient) Case Management (In-Patient) Claims
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Phone / Fax Tel: (562) 435-3333
Tel: (562) 435-3333 X 308 Fax: (562) 595-0673 Tel: (562) 435-3333 X 283 Fax: (562) 216-5439 Tel: (562) 435-3333 X 214 Fax: (562)
Tel: (562) 435-3333 X 224 Fax: (562) 981-7431 Tel: (562) 435-3333 X 255 Tel: (562) 435-3333 X 283 Fax: (562) Tel: (562) 435-3333 X 242 Fax: (562) 216-5437 Tel: (562) 435-3333 X 257 Fax: (562) 216-5437 Tel: (562) 435-3333 X 273 Fax: (562) 427-2781 Tel: (562) 435-3333 X 265 Fax: (562) 216-9054
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Accountable Heath Care IPA Provider Policy and Procedures
PRIMARY CARE PHYSICIAN’S ROLES
Manager of Care – Manages all care throughout the patient’s membership beginning with the initial health assessment. Caregiver for Routine Health Needs – Provides evaluation, diagnosis and treatment for the member’s routine health needs. Coordinator of Care – Assesses the member’s need for specialty services, determines the most appropriate and cost effective source of care as well as coordinates that care. Facilitator – Requests pre-authorization for services as necessary, orders and schedules tests/procedures and coordinates referrals. Monitor – Provides health care surveillance with regard to primary, secondary, tertiary prevention. Evaluates the outcome of services and applies results of treatment to planning for ongoing care.
PRIMARY CARE PHYSICIAN SERVICES COVERED UNDER CAPITATION
I. OFFICE AND HOSPITAL VISITS 9 9 9 9 9 9
Evaluation, test interpretation, diagnosis and treatment of illness or injury; Counseling and consultation with member and member's family; Referrals for specialist/ancillary services; Submission of encounter data; Member health education services; 24-hour on-call coverage.
OFFICE VISITS 9 Regular office visits and health appraisal examinations, including all routine tests performed in Professional’s office. 9 New/Established Patients Visits (including emergent/urgent/after hours) 9 Well Child Care/School physicals/Preventive Medicine 9 CHDP Assessment of all Medi-Cal Beneficiaries under 21 years of age.(Provider can bill Blue Cross, Molina, and LA Care directly for CHDP services for Medi-cal and Healthy Families enrollees.) 9 Routine Health Assessments/Physical Examinations
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Accountable Heath Care IPA Provider Policy and Procedures FACILITY VISITS 9 Admissions/Initial Hospital Visits (Optional. IPA has Hospitalist coverage) 9 Attendance at emergency room (Optional. IPA has Specialist coverage) 9 Subsequent Hospital and Discharge Visits (Optional. IPA has Specialist coverage) 9 Critical Care Visits (Optional. IPA has Specialist coverage) 9 Nursing Facility Visits (Optional. IPA has Specialist coverage) 9 Extended care facility visits (Optional. IPA has Specialist coverage) COMPLEX HOME CARE 9 Supervision of complex home care involving ancillary personnel (e.g., home TPN, tube feeding, antibiotics), although the provision of such services may warrant additional payment as determined by IPA in its discretion. Any such additional payments shall be subject to IPA’s utilization review procedures. (Optional. IPA has Specialist coverage) II.
OFFICE SERVICES 9 Audiometry& Snellen Vision Screening 9 Venipuncture/Specimen Collection/Handling 9 Spirometry/Oximetry 9 TB Skin Test 9 Urinalysis Dipstick 9 Urine Pregnancy Test 9 Occult Blood Stool Test 9 Interpretation of results of clinical tests provided by laboratories contracted with IPA.
III.
OFFICE PROCEDURES 9 Therapeutic Injection 9 Dressing Localized Burns 9 Anoscopy 9 Pelvic Exam (no pap smear performed) 9 Impacted Cerumen Removal
IV.
OFFICE MEDICAL SUPPLIES 9 Bandages/Band-Aids/Gauze/Tape/Dressings 9 Other routine Medical supplies (non-routine Medical supplies shall be billed at Professional’s cost, subject to IPA’s Utilization Review Procedures). 9 Sterile Suture Tray 9 Arm slings and Splints 9 Syringes 9 Sample Medications 9 Ice Packs 9 Crash Cart
V.
REFERRAL 9 Referral of Enrollees to appropriate consulting Physician or ancillary services as Medically necessary and according to guidelines established by IPA.
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Accountable Heath Care IPA Provider Policy and Procedures
CONTRACTED HEALTH PLANS
AETNA:
Commercial Members
ANTHEM BLUE CROSS:
Commercial Members Medi-Cal Members Healthy Family
BLUE SHIELD:
Commercial Members Healthy Family Senior
CARE FIRST:
Commercial Members Medi-Cal Members Healthy Family Senior
CIGNA:
Commercial Members
CITIZEN CHOICE::
Senior
EASY CHOICE:
Senior
HEALTH NET:
Commercial Members Medi-Cal Members Healthy Family Salud AIM
L. A CARE:
Medi-Cal Healthy Family Senior
MOLINA:
Medi-Cal Members Healthy Family Senior
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Accountable Heath Care IPA Provider Policy and Procedures
CONTRACTED PROVIDERS
SPECIALIST: X-RAYS: LABORATORY SKILLED NURSING FACILITY: DME: PHYSICAL THERAPY
Providers are advised to utilize the contracted specialists and facilities only.
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Accountable Heath Care IPA Provider Policy and Procedures INTRODUCTION
Accountable Health Care IPA would like to take this opportunity to welcome you to our health delivery network. The primary care physician plays a central role in the delivery of medical services to AHC IPA members. In addition to providing comprehensive office care, the primary care physician also coordinates the full range of specialty, ancillary, hospital, and home care services for our managed care members. Together, AHC IPA and its network of independent, participating primary care physicians set the standards for participating providers to deliver, quality and cost-effective medical care. Our participating physicians and we have long recognized “quality” as the single most important element in our system. We believe that we can continue to work together so that our members receive quality care and we can provide a model for the delivery of medical care for others to emulate. The policies and procedures in this manual is designed as a reference guide to assist you and your staff in providing care to all AHC IPA members (Medi-Cal, Commercial, Healthy Family, Salud and Medicare) enrolled in AHC IPA contracted HMOs. (Please see the list of all AHC-IPA Contracted HMOs) While it is true that HMOs drive the main health care delivery system, AHC IPA provides assistance in obtaining other benefits or to help in resolving perceived problems that individual providers/members felt they encountered when seeking services. We hope that you find this manual to be of value and we welcome comments and suggestions to improve it. This manual does not address clinical decisionmaking, which remains in your professional hands. To foster patient/provider relationship and promote appropriate use of services, AHC IPA sends out welcome letters, and any other information to those members who have selected our IPA as their Medical Group. We are happy to have you as a participating primary care physician with AHC IPA and look forward to a good and lasting working relationship. If you have any questions, please contact Provider Relations at (562) 435-3333.
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Accountable Heath Care IPA Provider Policy and Procedures Member Services
Welcome to our Medical Group Practice. As a new member of AHC IPA and as your provider, we will work hard to meet your health care need. An important part of staying healthy is to have regular check-ups, immunization and other preventive health care services. Your Primary Care Physician (PCP) will provide you with all these services. If it is determined that you will require specialty care or other services such as x-rays, your PCP will make sure that you receive these services. To enable us to effectively serve your health care needs, it is important, and a requirement, for an Initial Health Assessment to be scheduled within 90 days from your effective date. Your Primary Care Physician is Dr.___________________________________ You can reach your PCP at (_____)_________________ to schedule your Initial Health Assessment and any other appointments, thereafter. For any urgent health problems, during the day or night, please contact him/her and he/she will advise you on what to do. Accountable Health Care IPA assures that members will not be discriminated against because of their race, ethnicity, color or national origin, religion, sex, age, marital status, mental or physical disability, sexual orientation, genetic information or source of payment. At all times, members will be treated with respect, dignity and consideration of privacy If you have any questions or concerns regarding this notice or your financial liability for denied charges, please contact (heath plan name) at (heath plan phone #) The California Department of Managed Health Care is responsible for regulating health care services plan. The department has a toll free telephone number (1-888-HMO-2219) to receive complaints regarding health plans. The hearing and speech impaired may use the California Relay Service’s toll free telephone number 1-877-688-9891 (TDD)) to contact the department. The department’s Internet web site (www.hmohelp.ca.gov) has complaint forms and instruction online We are committed to providing and improving quality care. If you would like a copy of our Quality Management Program please contact our QM department at (562) 435-3333. We are looking forward to serving you. Sincerely,
Provider Relations
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Accountable Heath Care IPA Provider Policy and Procedures Mission: To promote and maintain quality of service and care to all AHC IPA members. Goals:
To implement an effective process to enhance the quality of member relations and reduce organizational concerns in order to emphasize effective operations within AHC IPA.
To keep all members informed of their rights and responsibilities as patients of AHC IPA.
To achieve and maintain an acceptable level of satisfaction regarding the care and service provided to all AHC IPA members.
To evaluate and track member grievances regarding the delivery of care and services to all AHC IPA members.
Objectives:
Through welcome letters, all new members of Accountable Health Care IPA are informed of what Accountable Health Care IPA is all about, its services and programs.
Procedures regarding access to care and services are explained including information on how to file a complaint with the health plan or Department of Managed Health Care.
Provide a copy of the Member Rights and Responsibilities as new patient of AHC IPA
Policy AHC IPA participating providers and members will abide by the rights and associated responsibilities of the members in the process of health care service delivery. Accountable Health Care IPA providers and members will be provided with a copy of the members’ Right and Responsibilities. The Providers and members also will be notified of revisions or updates in these documented rights and responsibilities.
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Accountable Heath Care IPA Provider Policy and Procedures Member’s Rights The AHC IPA Member has the right to:
Be informed about the AHC IPA, its services and participating providers and the health care service delivery process.
Be treated with respect and dignity without regard to Age, gender, sexual orientation or cultural, economic, educational or religious background.
Be provided with information on how to obtain care after normal office hours and how to obtain emergency care including when to directly access emergency care or use 911 services.
Be informed of the name and qualifications of the physician who has primary responsibility for coordinating the member’s care; and be informed of the names, qualifications, and specialties of other physicians and non-physicians who are involved in the member’s care.
Have 24-hour access to the member’s primary care physician (or covering physician).
Receive comprehensive health assessment, including preventive healthcare
Actively participate in decisions regarding the member’s health care and treatment plan
Receive complete information about the diagnosis, proposed course of treatment or procedure, alternate courses of treatment or non-treatment, the clinical risks involved in each, and prospects for recovery in terms that are understandable to the member, in order to give informed consent or to refuse that course of treatment.
Be informed of appropriate or medically necessary treatment options for the member’s condition, regardless of cost or benefit coverage.
Have access to their entire medical records and health information in accordance with the state and federal law and kept them confidential
Be informed that they have a right to transfer to any provider in the AHC IPA network.
Change his/her primary care physicians to another PCP who participate in AHC IPA network by contacting the Member Services Department.
Be informed of continuing health care requirements following office visits, treatments, procedures and hospitalizations and receive reasonable continuity of care
Be informed of the termination of a primary care provider or practice site and receive assistance in selecting a new primary care provider or site in this situation.
Seek a second opinion from another specialist within Accountable Health Care IPA
Be informed of the member complaint/grievance and appeal process including how to express a complaint and/or file a regular or expedited appeal.
Receive free language interpretation services by phone or by person and/or right to refuse a free telephone or free face-to-face interpreter services.
File a complaint or grievance if linguistics needs are not met.
Have educational brochures and other materials for the purpose of understanding the member’s disease condition.
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Accountable Heath Care IPA Provider Policy and Procedures
Access or referred to community resources for health education.
Received information and be informed of the methods by which advance directive is executed.
Not to be discriminated against when an advance directive has been completed or refused.
Be informed of emergent and non-emergent benefit coverage and cost of care, and receive an explanation of the member’s financial obligations as appropriate, prior to incurring the expense (including co-payments, deductibles, and co-insurance).
Examine and receive an explanation of bills generated for services delivered to the member.
Be provided with information on how to submit a claim for covered services.
Member’s Responsibilities The AHC IPA Member has the responsibility to:
Be on time for all appointments and notify the provider’s office as far in advance as possible for appointment cancellation or rescheduling.
Provide the member’s health care provider with complete and accurate information, which is necessary for the care of the member.
Contact the member’s primary care physician or on call physician for any care which is needed after normal office hours.
Carry out the treatment plan, which has been developed and agreed upon by the health care provider and the member.
Obtain an authorized referral from the member’s primary care physician for a visit to a specialist and/or to receive any specialty care.
Report changes in the member’s condition according to provider instructions.
Inform providers of the member’s inability to understand the information given to him/her.
Treat the health care providers, staff and members with respect.
Be familiar and comply with the AHC IPA’s health care service delivery system regarding access to routine, urgent and emergent care.
Contact the AHC IPA Member Services Department or the member’s Health Plan Member Services Department regarding questions and assistance.
Be familiar with the benefits and exclusions of the member’s health plan coverage as well as copayment for services (if applicable)
Have all of these responsibilities apply to the person who has the legal responsibility to make health care decisions for the member.
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Accountable Heath Care IPA Provider Policy and Procedures
Member Complaint, Grievance and Appeal Process ALL Contracted Health Plans do not delegate complaints and grievances of members. AHC IPA staff members and designees are instructed to direct the members to call / write to Member Services Department of the Health Plan to file a grievance. General Procedure: 1.
The staff member receiving the complaint/grievance documents member complaints and grievances on an AHP Grievance Form. The documentation includes the name of the member, the date the complaint/grievance is received and a brief description (including the name of any employee or provider involved). If the complaint/grievance is serious, the member may be requested to provide a written description of the incident.
2.
The AHP Grievance Form, written complaint/grievance or appeal is delivered to the Quality Management Director before the end of the business day that the complaint/ grievance is received.
3.
Opportunities for improvement are identified by gathering the appropriate information and by assessment and evaluation. Decisions are made regarding which opportunities for improvement to pursue.
4.
The information is processed according to the type of situation and according to the clinical urgency of the situation.
5.
Interventions to improve the system and provider performance are implemented.
6.
Urgent or grievous problems are followed up immediately by telephone and may require intervention by the Medical Director.
7.
The information is reported to the Quality Management Committee.
8.
Staff, members and providers are informed of the results of the quality improvement process.
9.
Evaluations are conducted to determine whether interventions have been effective.
Quality of Medical Care Complaints/Grievances Procedure: 1.
The Quality Management Director or designee notifies the member in writing within required time frames that an internal review of the complaint/grievance is being conducted and that he/she will be notified of the results in writing.
2.
If the complaint/grievance was forwarded from a third party (e.g., health plan), that party will also be notified in writing within required time frames of the review and the results.
3.
If an AHC IPA employee or provider is named in the complaint/grievance, the Notice is forwarded to that person and a written response requested.
4.
If appropriate, the medical record of the member is requested by the Quality Management Director and sent to the Quality Management Chairperson or an appropriate Quality Management Committee physician member for review.
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Accountable Heath Care IPA Provider Policy and Procedures 5.
The Quality Management Director or the Quality Management Committee Chairperson or designee interviews the employee or provider involved, as appropriate.
6.
If a potential opportunity to improve care or if a problem is identified, it is documented on a Member Clinical Care Review Form for Physician Reviewer and all investigation documents and the member records are referred to the Quality Management Committee for review and recommendation and performance improvement action.
7.
In all cases, the internal investigation will be concluded within required time frames of the receipt of the complaint. The Quality Management Committee may make extensions as they are needed for thorough investigation and appropriate action and follow-up.
8.
Complaints regarding providers are filed and tracked in the provider’s Quality Profile for use in re-credentialing and for other evaluation and tracking purposes.
9.
Required reports are made to contract Health Plans but the provider or employee name is not included in the report.
10.
The Risk Management Department is notified according to AHC IPA approved policies and procedures.
11.
The member is notified in writing of the resolution. Instructions regarding his/her right to appeal the decision are also given. Confidentiality is maintained throughout the process. Legal counsel may be consulted prior to responding to the member in writing.
Administrative Complaints/Grievance Procedure: 1.
Administrative complaints that cannot be resolved by telephone are investigated and documented on an AHC IPA Grievance Form by the designated member of the department involved in the complaint. The complaint is documented as part of the department’s Quality Management activity and the Notice is forwarded to the Quality Management Director for tracking.
2.
If the complaint involves interpersonal behavior of an employee or provider, the Quality Management Director or the Quality Management Committee Chairperson for appropriate action investigates it. The conclusions are reported to the departmental supervisor or the Medical Director, as appropriate.
3.
Complaints that cannot be resolved by telephone, as well as written complaints, are responded to in writing with consideration given to confidentiality. The Risk Management Department personnel (COO) assist in the process as appropriate.
4.
Complaints of a serious or recurring nature (which arise as the results of third party actions or failures to act) are forwarded to that party for evaluation and corrective action.
Appeal Process The complaint/grievance procedure and appeal process are outlined in the information provided to members on enrollment through the health plan and in addition to the procedures listed in this Member Complaint, Grievance and Appeal Process, include the following:
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Accountable Heath Care IPA Provider Policy and Procedures
The documented information, activities and response to an appeal will include: 1) 2) 3)
The substance/issues and the actions taken The investigation including any aspects of clinical care The resolution of the appeal including: a) At least one level of review by a panel of individuals who were not involved in the original decision b) The right of the member to appear before the panel
Note: The health plan must handle the adjudication of final appeals, as this process will not be delegated to the IPA. 4)
The member notification of the disposition of the appeal and the right to further appeal according to appropriate regulatory language
. Reporting to Contracting Health Plans All complaints, grievances and appeals are reported to health plans according to health plan contractual agreements.
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Accountable Heath Care IPA Provider Policy and Procedures QUALITY MANAGEMENT PROGRAM Scope The scope of the program is comprehensive and includes activities that have a direct or indirect influence on the quality and outcome of clinical care and service delivered to all AHC IPA members and the service provided to employers and provider panel members. The program addresses issues relevant to the enrolled member population. The activities monitored and reviewed by the QM Program includes but are not limited to the following: Medical records review Member satisfaction surveys Provider satisfaction surveys Member written/verbal statements Provider written/verbal statements Focused review when service or quality issues are identified Clinical Practice and Preventive Care Guidelines Under/Over Utilization of services Complaint and Grievance Resolution Appeals Resolution Compliance with Federal, State, Health Plan, DHS, and other Accreditation Standards Credentialing Quality of care is accessible and efficient, provided in the most appropriate setting and achieves the optimal patient outcome in a coordinated and continuous manner. GOALS and OBJECTIVES The goal of AHC IPA’s Quality Improvement Program is to continuously maximize and improve the health care services delivered to AHC IPA’s members. This goal can be achieved through the following objectives: 1. To set standards to evaluate the provision of health care by the actual providers or the organized system through which these providers deliver care. 2. To assure accessibility and timeliness of all services, preventative, primary, specialty, emergency or ancillary care delivered in inpatient and ambulatory settings. 3. To monitor practice patterns and utilization of health services. 4. To assure that medical services are delivered at the appropriate level of care in an effective and efficient manner. 5. To assure objective and systematic monitoring of important aspects of the treatment as well as the staff delivering the care. 6. To ensure a system of communication that is timely and reports through appropriate channels, to appropriate individuals. 7. To assure that all quality of care issues and administrative issues are monitored and resolved through an internal grievance process whether it is a member-initiated grievance, i.e., denial of services/payment or a physician/provider-initiated grievance. Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures 8. To ensure that credentialing is done on all physician providers and that the recredentialing process includes re-review of all aspects of credentialing and review of performance data/information obtained from member grievances, member satisfaction surveys, results of quality of care studies, utilization management, on-site facility audits, and any other source deemed appropriate to provide information to assist in the decision-making process. 9. To monitor and evaluate patient safety through different aspects of quality management, such as, but not limited to grievances, survey results, or potential quality issues that are identified through utilization reviews. Physician offices are monitored through facility audits for practices that could pose a threat to patients’ safety. Program Structure: A.
Quality Management Committee.
The Quality Management Committee is an interdisciplinary committee of the Governing body with membership that is appointed by the Medical Director. It includes administrative staff involved in the quality of care and service and providers that are representative of the Provider Panel. Only licensed practitioners have voting rights on issues involving clinical decisions. Issues that arise prior to scheduled QM Committee meetings and need immediate attention are reviewed by the Medical Director and/or designated person(s) and/or a subcommittee and are reported back to the QM Committee, if applicable. 1. Structure/Membership a. b. c. d. e. f. g. h. i.
Chairperson (usually a physician) Medical Director Providers that are representative of the Provider Panel- PCP, Pediatricians, OB/GYN and specialist physicians and ancillary providers Quality Management Nurse Credentialing/Membership Committee Chairperson or designee Utilization Committee Chairperson or designee Utilization/Case Management Nurse Health Education Coordinator Invited members of the management staff to present opportunities to improve care/service or problems and/or for assistance to the Committee in identified problem solving, as appropriate.
Members are rotated annually to assure broad representation but serve One- (1) year term to ensure continuity. 2.
Meetings and Participation a. The Committee meets quarterly, on every 4rd Tuesday at 2:00 PM at the AHC IPA Administrative Office or at any designated date and time and may meet more frequently if deemed necessary by the Chairperson, Medical Director, Administrator or the Governing body. The number of members required for a quorum shall be three (3) licensed providers of AHC IPA.
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Accountable Heath Care IPA Provider Policy and Procedures b. Active participation on the Committee includes consistent meeting attendance and involvement in, discussion of agenda items, establishment of clinical practice guidelines, selection of monitoring measures used to assess performance and studies, analyzing results and assisting in follow-up and problem resolution as requested by the Committee. c. Health plan medical directors (or their designee) may attend portions of meetings but must arrange attendance in advance and sign a confidentiality statement. B.
Utilization Management Committee The Utilization Management Committee oversees the implementation of comprehensive, systematic, continuous processes, which make the Utilization Management Program effective. The UM Committee actively manages utilization of services by making the most appropriate use of available healthcare resources. Sound utilization plans are defined, developed and executed by the Utilization Management Committee.
C.
Credentialing Committee The Credentialing Committee is responsible for review and approval of credentials for AHC IPA’s provider network. The committee approves credentialing policy for internal use and reviews activities associated with the provider’s credentialing performance. The committee ensures the management of credentialing activities and takes action to resolve identified barriers to the credentialing process.
D.
Peer Review Committee: Peer review is defined as the program and review process set-up to check the clinical competence and performance of individuals with clinical privileges in the IPA. The reviews will look for licensure and adherence to the IPA's clinical practice guidelines tempered by medical ethics. Peer Review Committee minutes are strictly confidential and may not be subject for review by any outside organization (except authorized by law).
E.
Risk Management Committee: The Risk Management Committee is responsible for overseeing the implementation of the Risk Management Program through risk identification, evaluation and control.
Quality Improvement Activities (QIA): Health Education AHC IPA develops and implement standards for disease prevention, health promotion, and preventive health services to its members and community at cost effective practices of managed care through appropriate cultural and linguistic approaches. AHC IPA empowers and encourages its members to take an active role in their health care by providing patient education and preventive services to reduce health risk behaviors, attain optimum health outcomes and improve health status through health education and effective management of medical conditions. AHC IPA takes a proactive approach in Health Education in cooperation with the Health Plan, St. Mary Medical Center Health Education Department and local community Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures resources. Members may self-refer or be referred to health education by their provider and/or AHC IPA QM/UM Department. Analysis of the effectiveness of the Health Education program is measured through: Medical record documentation of health education provided during office visits health education literature, referrals to community and hospital health education resources, as appropriate. Member satisfaction survey will assess the availability of information on health education classes, available screening program and/or general health education literature availability in the office. Members are given evaluation sheets after each class to assess and ensure compliance and adherence to the program. Members identified through Utilization Review will be sent calendars of the upcoming classes offered at AHC IPA through SMMC Health Education Department at the beginning of the year. Classes being offered are advertised via newsletters, fliers, letters or fliers posted at the AHC IPA premises by SMMC Health Education Department. The following classes are offered: Smoking cessation Coping with loss/Grief Diabetes High Blood Pressure Preventing Heart disease Advance Directives Osteoporosis
Stress Management Asthma AID Cholesterol Management Weight Management Independent Living skill Prenatal
Others
Accessibility of Service AHC IPA establishes and maintains appropriate accessibility of primary care, behavioral health care and member services. Standards for medical care are set to ensure that members have access to routine, preventive and urgent care appointments, after-hours care, which includes 24-hour physician access for members and telephone services. Standards are realistic for the community, delivery system, clinical urgency of the situation and clinical safety. Afterhours access is provided through live answering service. Physicians are paged and are expected to respond within the hour. In cases where a prudent layperson considers a medical situation an emergency, the person is instructed to call 911 or go to the nearest emergency room. Standards for behavioral care access include care for a non-life threatening emergency within 6 hours; urgent care within 48 hours; and appointment for routine office visit within 10 business days. Telephone access standards are also established to access behavioral health screening and triage. A non-recorded voice is reached within 30 seconds, and abandonment rate does not exceed at any given time. Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures Annual performance evaluations are measured against standards for access to routine care appointments; urgent care appointments; after-hours care; and telephone services. Behavioral access standards are measured through member surveys or analysis of complaints. Member Satisfaction AHC IPA implements mechanisms and monitors member satisfaction with its services and identifies potential areas for improvement. Complaints and appeals relating to quality of care, access, attitude and service, and financial issues are evaluated to identify areas of dissatisfaction. Results are analyzed and compared against the goal set by AHC IPA. Opportunities for improvement are identified and improvement actions are pursued. Results are communicated through newsletters, special mailings and appropriate meetings. Continuity and Coordination of Care: 1)
Medical Care Coordination
Accountable Health Care IPA monitors and takes actions to improve continuity and coordination of care across its network. Continuity and coordination of care is monitored across practices and provider settings, transitions of care, or communications through grievances and surveys. a. Different settings include outpatient, laboratory, pharmacy, inpatient, surgery center, home care, nursing facilities or other types of locations where care is rendered. b. Transitions in care include changes in management of care between practitioners, changes in settings, enrollment or disenrollment in DM Programs, or other changes in which different practitioners become active or inactive in providing ongoing care for a patient. c. Communication and coordination issues, as raised by the practitioners through provider surveys, or complaints filed by providers as well the members. 2)
Termination of Provider Accountable Health Care IPA uses information to coordinate transitions in medical care across the delivery system and assures continuity of care upon termination of practitioner contracts. When a practitioner’s contract is terminated, AHC IPA will provide continued access to the affected members. (Affected members are those who have (a) number of visits to the practitioner within a specified time period; (b) series of referrals for the same type of care over a specified period of time; and (c) received periodic preventive care by the same PCP or practice site).
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3)
AHC IPA will coordinate with the health plans in notifying members affected by the termination of a primary care practitioner or practice site at least 30 calendar days prior to the effective termination date and assist them to select a different practitioner or site.
AHC IPA, similarly, will notify affected members in writing, regarding the specialist or specialty group terminations at least 30 days in advance of the termination and assist them to select a different specialist or practice.
Members undergoing active treatment for a chronic or acute medical condition will have access to their discontinued practitioner through the current period of active treatment or for up to 90 days, whichever is shorter.
Members in their second or third trimester of pregnancy will have access to their continued practitioner through the postpartum period.
AHC IPA will work with practitioners who are no longer under contract to develop a reasonable transition plan for each member in active treatment. Specialist Termination from Case Management Specialist contracts state that the specialist or specialty group will notify affected members of the termination of an individual specialist or entire group at least 30 calendar days prior to the effective date of termination. The individual specialist or specialty group is required to submit a list of AHC IPA members who are currently being seen and treated and may be affected by the termination.
(Affected members are defined as members who have made a specified number of visits to a specialist, or members who have a chronic condition that a specialist has managed over a specified period of time). 4)
Behavioral Health Care Coordination Behavioral health care is a carved out services for some of the health plans for Medi-Cal members but it is a covered benefits for Medicare members. PCP may be involved and responsible in some aspect of behavioral health care of the members. He/she is a liaison between member, AHC IPA, behavioral health care providers and the HMO. AHC IPA will continue to credential behavioral health care providers. One of the provider will be a part of the UM committee. Primary care providers are responsible for referring the member to AHC IPA. AHC IPA will review treatment authorization request and involve behavioral health care provider for decision as deemed necessary. Behavioral health care practitioner will be actively involved in the implementation of the behavioral health care aspect of the UM program. (He/she will be involved in setting policy, reviewing cases and participating in the committee meetings if necessary)
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Accountable Heath Care IPA Provider Policy and Procedures Referring a member to a behavioral health care provider for in-patient and/or out-patient care, AHC IPA will utilize member’s assigned HMO facility. HMO is responsible to credential behavioral health care facility. AHC IPA will collaborate with health plans in the promotion and utilization of preventive programs that address behavioral health issues through education of medical and behavioral health practitioners and their staff. Clinical Practice Guidelines AHC IPA is accountable for adopting and disseminating clinical practice guidelines relevant to its enrolled membership for the provision of acute, chronic, and behavioral health services. AHC IPA adopts clinical practice guidelines relevant to its population. At least two of the adopted clinical practice guidelines are the clinical basis for Disease Management. AHC IPA’s UM Committee adopts guidelines through recognized sources or organizations that develop evidence-based clinical practice guidelines. These include professional medical associations, voluntary health organizations and NIH Centers and Institutes. Guidelines that have been in effect for at least two years are reviewed by UM Committee. However, when new scientific evidence or national standards are published before the two-year cycle, the committee members or appropriate practitioners initiate the review process and the guideline is updated as necessary. Practitioner involvement is not required when guidelines have been adopted from recognized sources. AHC IPA is responsible for distributing the guidelines to appropriate practitioners. Communication mechanisms include newsletters, practitioner manuals, special mailings, or new practitioner orientation manuals. Annually, performance is measured against at least two aspects of each of the 4 guidelines, including behavioral health that relates to the process of care. AHC IPA ensures that its UM criteria, health education, and disease management programs are consistent with the guidelines, as long as the requirement in the guidelines is a part of the member’s covered benefits. Language Interpretation Services AHC IPA collaborates with the health plans in order to ensure the rights of the members to free language interpretation of clinical care and services. When a non-English member is identified, steps are taken to ensure that the member’s needs are appropriately provided. Clinical Quality Improvements Accountable Health Care IPA will measure quality of clinical care and verify areas of improvements that will affect the clinical quality of care that members receive. AHC IPA will use various sources of information, including reports from the contracted health plans. Trend results in utilization rates of preventive services, such as mammography, and other HEDIS measures will be considered as opportunities for improvement.
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Accountable Heath Care IPA Provider Policy and Procedures Service Quality Improvements Examples of service improvements are: Availability of practitioners in any specialty; Accessibility of appointments, in any specialty; Grievance resolution; Availability of language interpreters after hours; Member satisfaction with providers and practitioners; Practitioner satisfaction with the UM process; AHC IPA will use various sources of information, and the results will be considered as opportunities for improvement. Medical Record Documentation AHC IPA requires that medical records be maintained in a manner that is current, detailed and organized, and which permits effective and confidential patient care and quality review. Policies and procedures address confidentiality of medical records, documentation standards, medical record keeping system and standards for the availability of medical records. Policies and procedures also reflect all services provided directly by a PCP, all ancillary services and diagnostic tests ordered by a practitioner, all diagnostic and therapeutic services for which a member was referred by a practitioner, such as: home health nursing reports, specialty physician reports, hospital discharge summaries, physical therapy reports, ER reports. AHC IPA established standards that include: medical record contents, medical record organization, information filed in medical records, ease of retrieving medical records, confidential patient information, and performance goals for participating practitioners. Performance monitoring will be conducted in time for providers’ recredentialing cycle to assess the quality of medical record keeping, completeness of the record, and documentation of continuity and coordination of care. Corrective actions include: Letters to practitioners with identified deficiencies that identify compliance issues and a suggestion of an action plan for improvement Sample model medical record forms, which will facilitate the organization of the information Publish best practices for medical record documentation in the newsletter Provide resources and new information or updates relating to best practices in medical record documentation via the newsletter. Contracts and Provider/Practitioner Requirements: Contracts Provider and practitioner contracts and employment agreements include a clause that requires participation in AHC IPA Quality Management activities and adoption of AHC IPA Quality Management Policies and Procedure as well as access to the medical records of members. The provider / practitioner contracts specifically require that the provider cooperate with quality management activities and allow AHC IPA access to medical Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures records to the extent permitted by state law. Open communication between providers and patients is allowed regarding appropriate treatment alternatives. The AHC IPA does not penalize providers for discussing medically necessary or appropriate care for the patient. Practitioners may freely communicate with patients about their treatments, regardless of benefit coverage limitations. The contract specifies that the practitioners and providers maintain the confidentiality of member information and records. Advance Disclosure of Participation Accountable Health Care IPA provides physician applicants with written notice of the rules of participation, including terms of payment, credentialing policies directly related to participation decisions. Written notice of material changes in participation rules will be distributed prior to being put into effect. Practitioner Exclusions Accountable Health Care IPA does not prohibit employment or contracting with individuals or entities that are excluded from participation under Medicare, or those who “opt out of Medicare. Practitioners who are excluded, sanctioned or “opt out” of Medicare may not provide care or receive CMS funds for care rendered to Medicare beneficiaries. Availability of Primary and Specialty Care Providers AHC IPA implements mechanisms to assure the availability of primary care providers and ensures that its network has sufficient numbers and types of primary and specialty care practitioners to meet the needs of its membership. Primary care practitioners include internists, family practitioners, pediatricians, obstetricians / gynecologists, physician assistants and nurse practitioners. The number and geographic distribution of practitioners serving as primary care physicians are assessed through a percentage of members within a certain number of miles, number of sites accepting new members for primary care in each geographic area, acceptable driving time to primary care sites, or reports of surveys regarding accessing primary care physicians. High volume specialty care practitioners include OB/GYN, dermatologists, orthopedics, and other specialists determined by AHC IPA as high volume based on number of claims or encounter data submission. Geographic distribution of high volume specialists are assessed through a percentage of members who have specialist within certain number of miles, ratio of member to specialist availability in each area, acceptable driving time to specialty care sites, or results of member surveys regarding availability of specialists. AHC IPA assesses the cultural, ethnic, racial and linguistic needs of its members and adjusts the availability of practitioners within its network as necessary. Pods are being developed in several hospital sites to increase the distribution and availability of primary and specialty care providers to all AHC IPA members.
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Accountable Heath Care IPA Provider Policy and Procedures Annually, assessment of number and geographic distribution of primary and specialty care providers are measured. Member satisfaction surveys are evaluated regarding the practitioner availability. Confidentiality AHC IPA treats with confidentiality all materials being reviewed by each Committee (QM, UR, Risk Management, Credentialing, and Peer Review). All members of each Committee shall be required to sign a confidentiality agreement annually. The confidentiality agreement shall be maintained in the provider file or employee files as appropriate. All peer review records and proceedings shall be maintained in a confidential manner. Health Plan Representative may attend as an observer and will be asked to sign the required Confidentiality Statement.
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FACILITY SITE REVIEW Purpose: All applying Provider, (Family practice, General practice, Pediatrician Internist, Ob/Gyn and behavioral Health providers) and Ob/Gyn (as specialist) will have facility site review by a Credentialing/QM staff of AHC IPA. High volume behavioral Health providers will have an audit performed upon recredentialing. The purpose of the site visit is to ensure that provider patient care sites meet AHC IPA environmental standards for safety and cleanliness, for medical record documentation of patient history and physical, diagnosis and treatment, education and patient satisfaction. The site visit will provide a mechanism for provider education and facilitate continuous improvement in the provision of patient care and service. Scope: All Primary Care Providers (General Practice, Family Practice, Pediatric, Ob/Gyn and Internist) offices as well as Ob/Gyn specialist must be site audited prior to acceptance into AHC IPA provider panel. Policy: The State of California Department of Health Care Services (DHCS) requires all Health Plans participating in the Medi-Cal Managed Care Division (MMCD) Program to review all participating Primary Care Provider (PCP) sites established in statute by Title 22, CCR, for participation in the Medi-Cal Program and Title 28, CCR for Knox Keene-licensed health plans. MMCD Policy Letter 02-02 dated July 1, 2002 defines the standardized site review policy that is applicable to all Medi-Cal managed care health plan models and describes the system-wide process to minimize site review duplication and support consistency in PCP site reviews. This policy incorporates evaluation criteria and guidelines in compliance with DHCS contractual requirements. The site review process is part of the Health Plan’s quality improvement program that focuses on the capacity of the PCP site to ensure and support the safe and effective provision of clinical services provided at the primary care sites within the provider network. Primary care services include all health care and laboratory services customarily provided by or through a general practitioner, family practice physician, internal medicine physician, pediatrician or obstetrician/gynecology (OB/GYN) in accordance with State licensure and certification laws and regulations (Title 42, Code of Federal Regulations (CFR), Section 438.6). AHC IPA will conduct office site visit if member, health plan or any regulatory agency has complaints or concerns related to Physical Accessibility, Physical Appearance, adequacy of Waiting and Examination room space, and adequacy of equipments. AHC IPA will conduct site visit within 60 calendar days for every complaint received. AHC IPA will conduct follow-up visit within 60 calendar days after the deficiencies have been corrected. Provider will be monitored at least every six months for any complaint filled by the member, health plan or by any regulatory agency.
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Accountable Heath Care IPA Provider Policy and Procedures In case of additional complaint received within one year for the same issues, AHC IPA may not perform another site visit. If, additional complaint received regarding different office site (issues) criteria, AHC IPA will conduct another site review. Quality management coordinator will maintain grievance and appeal log. Grievance and appeals will be reported to the committee at each committee meeting. AHC IPA will also notify health plan upon receipt of the complaint. Facility site review and medical record review findings as well as any grievance will be a part of the credentialing file. Purpose A. The purpose of conducting site reviews is to ensure that all primary care sites where care is delivered to Accountable Health Care IPA (AHC IPA) members have sufficient capacity to:
B.
C.
Provide appropriate primary health care services;
Carry out processes that support continuity and coordination of care;
Maintain patient safety standards and practices; and
Operate in compliance with all applicable federal, state and local laws and regulations.
Credentialing and Re-credentialing
Prior to approval for use in providing services to members, all contracted or subcontracted sites where primary health care services are provided as part of the initial credentialing process are required by California statute (Title 22, CCR, Section 56230) to complete an initial site inspection and subsequent periodic site inspections regardless of the status of other accreditation and/or certifications other than for the Medi-Cal Managed Care program.
For a new provider on a site that has not previously been reviewed, initial provider credentialing and site review will occur simultaneously.
As providers at a site may change over time, the timeline for provider re-credentialing and subsequent site review survey may become independent processes that are not on a synchronized schedule.
Compliance with DHCS MMCD Policy Letter 02-02 Facility Site and Medical Record Survey Collaboration
This policy maintains a standardized system-wide process for conducting reviews of provider facility sites and medical records that minimizes site review duplication and supports consolidation and consistency of PCP site reviews in compliance with DHCS contractual requirements.
AHC IPA shall collaborate with all commercial, Medi-Cal and Medicare Managed Care Health Plan to establish systems and implement procedures for the coordination and consolidation of site audits for mutually shared primary care providers.
The Medical Director is ultimately responsible for site review activities.
AHC IPA does not delegate to other agencies/entities, facility site or medical record
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review responsibilities.
Definitions A. Corrective Action Plans (CAP) CAPs are required for:
All cited deficiencies with a conditional pass score of 90% or less on the site review and/or medical record review survey.
Focused reviews with cited deficiencies requiring a corrective plan.
Deficiencies identified by the Health Plan or regulatory agencies.
B. Focused Review – The focused review is a “targeted” audit of a specific site or medical record review that may be used to monitor providers between full scope reviews, to investigate problems identified through monitoring activities, or to follow-up on corrective actions. Procedures A.
Full Scope Site Review 1. Full Scope Site Reviews shall be the system-wide standard for conducting the initial and subsequent periodic reviews of contracted PCP and OB/GYN sites.
A Full Scope review consists of the MMCD Site Review Survey and Medical Record Review Survey.
A minimum passing score of 80% is required on both the Site Review Survey and the Medical Record Review Survey.
Reviewers shall only review survey criteria that are appropriate to their level of education, expertise, training, and professional licensing scope of practice as determined by the California statute.
The responsible reviewer for each survey shall be at minimum a registered nurse (RN), who shall sign the site review and/or medical record survey (MMCD Policy Letter 02-02 Review Tool criteria designates the level of reviewer).
2. The initial site review is the first onsite inspection of a site:
3.
That has not previously had a full scope site survey;
There is no evidence of a current passing survey completed by another local plan within the last three years;
When a contracted provider from an approved site moves to a new site that has not previously been reviewed;
A PCP and/or OB/GYN site that is returning to the Medi-Cal Managed Care Program and have not had a passing full scope survey within the past three years.
AHC IPA will waive the Full Scope Site Review Survey for a pre-contracted provider site if the provider or the Health Plan has documented proof that a current full scope survey with a passing score was completed within the past three years.
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Accountable Heath Care IPA Provider Policy and Procedures 4.
AHC IPA is responsible for tracking the survey status of each contracted Medi-Cal Managed Care provider site.
5.
AHC IPA is responsible to follow-up and closes any provider Corrective Action Plan(s) that is identified on the facility site and medical record reviews that is performed by health plan/ AHC IPA.
6
AHC IPA does not delegate site review responsibilities except health plan.
7.
After the initial full scope survey, the maximum time period before conducting the next required full scope site survey shall be three years.
8
AHC IPA may review sites more frequently when determined necessary based on monitoring, evaluation, or corrective action plan (CAP) follow-up issues.
B.
Facility Site Review Process 1.
The Certified Site Reviewer will conduct the Facility Site review using the MMCD Site Review Survey and accompanying interpretive guidelines.
2.
There are nine critical survey elements identified to have potential for adverse effect on patient health or safety.
The critical elements include: I. Exit door and aisles are unobstructed and egress (escape) accessible; II. Airway management equipment: oxygen delivery system, oral airway nasal cannula or mask, Ambu bag, appropriate to practice and populations served are present on site; III. Only qualified/trained personnel retrieve, prepare or administer medications; IV. Office practice procedures are utilized onsite that provide timely physician review and follow-up on referrals, consultation reports and diagnostic test results; V. Only lawfully-authorized persons dispense drugs to patients; VI. Personal protective equipment (PPE) is readily available for staff use; VII. Needle stick safety precautions are practiced on site; VIII. Blood, other potentially infectious materials (specimens) and regulated wastes sharps/biohazards non-sharps are placed in appropriate leak-proof, labeled containers for collection, processing, storage, transport or shipping; and IX. Spore testing of autoclave/steam sterilizer is completed (at least monthly) with documented results.
3. The PCP and/or site contact will be notified of all critical element(s), infection control and pharmacy deficiencies found during a full scope site survey, focused survey, or monitoring visit.
All critical element(s), infection control and pharmacy deficiencies shall be corrected by the provider within 10 business days of the survey date.
All corrected critical element(s), infection control and pharmacy deficiencies will be verified
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C.
as corrected by the Certified Site Reviewer within 45 days of the survey date.
Sites found deficient in critical element(s), infection control or pharmacy during the Full Scope Review will be required to correct 100% of the survey deficiencies regardless of the survey score.
Facility Site Review Scoring
When the facility site review has been completed, the Certified Site Reviewer will calculate the score following the guidelines specified in the survey tool. For scoring procedure, please see Facility Site guidelines.
At the Exit interview, the Certified Site Reviewer will discuss the findings with the PCP and/or site contact designee focusing on those areas that are critical element(s), infection control and pharmacy, and other areas requiring improvement(s) and the need for a corrective action plan.
MEDICAL RECORD REVIEW Procedures A.
Medical Record Review Schedule
Medical record reviews will be performed on all contracted PCP and OB/GYN sites using the Medical Record Survey tool.
Medical record reviews will be performed at the time of the scheduled site evaluation or another mutually agreed upon time.
PCP and OB/GYN sites are reviewed at least every three years. Medical records may be reviewed more frequently in order to address identified deficiencies or to monitor the implementation of a corrective action plan (CAP).
Medical records of new providers shall be reviewed within 90 calendar days of the date on which members are first assigned to the provider.
An additional extension of 90 calendar days may be allowed only if the new provider does not have sufficient assigned Medi-Cal managed care plan members to complete a review of 10 medical records.
If there are still fewer than 10 assigned medical records at the end of six months, a medical record review shall be completed on the total number of records available and the scoring shall be adjusted according to the number of records reviewed.
During the medical record review, the Certified Site Reviewer shall have the option to request additional records for review.
If additional records are reviewed, scores must be adjusted according to the number of records reviewed.
B. Record Selection
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Prior to the medical record review process, the Certified Site Reviewer will determine which populations (adult, pediatric, OB) are served by the site in order to determine the medical records that should be pulled for review and the audit tools that should be completed for that site.
The medical record score is based on a survey standard of 10 randomly selected records per provider consisting of five pediatric record and five adult and/or obstetric records.
For sites with only adult, only obstetric, or only pediatric patients, all ten records surveyed are only in that preventive care areas.
Sites where documentation of patient care by multiple PCPs occurs in thesame record shall be reviewed as a “shared” medical record system. Shared medical records shall be considered those that are not identifiableas “separate” records belonging to any specific PCP.
The selection criteria for shared medical records initial review is shown below: Number of Providers at Site
Number of SCFHP records to be pulled by site staff
1–3 4–6 >7
10 – 20 20 – 40 30 – 60
Number of randomly selected records to be reviewed 10 20 30
Records do not need to be pulled for specific providers, but should be pulled randomly from all providers.
Records should be for AHC IPA members only.
Each record should include at least three (3) visits within the past 12 months.
C.
Medical Record Review
The Certified Site Reviewer will randomly select 10 records (depending upon the number of providers at the site as described in the table above) to review.
The Certified Site Reviewer will conduct the reviews using the MMCD Medical Record Tool with accompanying interpretive guidelines.
Medical records are reviewed for format, legal documentation practices and documented evidence of the provision of preventive care and coordination and continuity of primary care services.
Preventive care criteria covers three content areas: pediatric, adult health, and obstetric services.
A tool will be completed for each specialty at the site (adult, pediatric, OB).
When each record has been reviewed, the certified Site Reviewer will calculate a combined medical record score to determine compliance or the need for a follow-up visit.
D.
Medical Record Scoring
When the medical record review has been completed, the Certified Site Reviewer will calculate the score adjusting the total points according to the number of records reviewed.
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For scoring procedure, see medical record review guidelines.
At the Exit interview, the Certified Site Reviewer will discuss the findings of the medical record review with the PCP/site designated contact focusing on those areas within the medical record tool requiring improvement(s) and the need for a corrective action plan.
Note:
Medical record should be in secure cabinet where there is no access to unauthorized individual and should be easily retrievable to the medical assistant Medical record should be organized and all medical record form is consistent with the regulatory agency requirement Medical record should be confidential and any information should not be shared with any unauthorized individual
SCORING Procedures A.
Scoring of Facility Site and Medical Record Review
Survey scoring is based on available documented evidence, actual demonstration of criteria being met, and verbal interviews with site personnel.
Calculation of scores is based on the total survey points, or on the adjusted survey points for “not applicable” items.
A score of at least 80% for the Facility Site Review and a score of at least 80% for the Medical Record Review must be achieved to pass the survey.
A full point shall be given if the scored element meets the application criterion.
All critical elements have a score or “weight” of two points.
Partial points shall not be given for any scored element that is considered only partially met by the reviewer.
Zero points shall be given if an element does not meet criteria.
The reviewer shall determine the “not applicable” (N/A) status of each criterion based on the sitespecific assessment.
All criteria scored as zero points or assessed as N/A must be explained in the comments section of the tool.
After the Facility Site Review, the Certified Site Reviewer will calculate the site score to determine the compliance rate.
The Site Review Survey contains a total of 150 points with the following compliance level categories: Compliance Categories Compliance Rate Exempted Pass 90% or above without deficiencies in critical elements, infection control and pharmacy
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Conditional Pass Not Pass
Accountable Heath Care IPA Provider Policy and Procedures 80-89% or 90% or above with deficiencies in critical elements, infection control and pharmacy Below 80%
The Medical Record Survey contains a total of 320 points with the following compliance level categories: Compliance Categories Exempted Pass 90% Conditional Pass 80-89% Not Pass Below 80%
B.
Compliance Rate
If a provider site receives a non-passing score by one Health Plan, the site shall be considered to have a non-passing score by all other Medi-Cal Managed Care health plans.
Corrective Action Plan (CAP) Notification (Exit Interview)
After completion of the review, the Certified Site Reviewer will discuss the findings of the facility and medical records evaluations and the required corrective actions with the PCP or site contact designee.
The Certified Site Reviewer shall review with the site contact all critical element(s), infection control and pharmacy deficiencies or other deficiencies determined by the reviewer to require immediate corrective action.
The Certified Site Reviewer shall inform the PCP/site contact that all critical element(s), infection control and pharmacy deficiencies need to be corrected within 10 business days of the survey date and verified as corrected by the Certified Site Reviewer within 45 calendar days.
Sites found deficient in any critical element(s), infection control and/or pharmacy during the Full Scope Facility Site Review shall be required to correct 100% of the review deficiencies.
At its direction, the Health Plan may decide to provide additional education, information, referrals, and/or supportive technical assistance to help the provider sites correct any cited deficiencies.
CAP Procedures A.
Corrective Action Plan (CAP). The CAP is a standardized, pre-formatted document developed by the MMCD Medi-Cal Health Plan Collaborative to assist the PCP in meeting MMCD Policy Letter 02-02 requirements. The CAP includes deficiencies noted during PCP and OB/GYN Facility Site and Medical Record Reviews, specified corrective actions, evidence of their corrections, date corrections were implemented, physician or designee responsible for corrective actions, name and title of Health Plan reviewer including verification of corrections. The CAP contains three (3) separate sections. Full Scope Facility Site Review Critical Elements Site Review Full Scope Medical Record Review
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B. C.
The CAP includes a Disclosure and Release statement regarding CAP submission timeline and authorization to furnish results of the reviews with corrective actions to Health Plans participating in the collaboration and government agencies that have authority over the Health Plan and authorized county entities in the state of California. The CAP informs the PCP that participating Health Plans have collaborated for Facility Site and Medical Record Review processes and have agreed to accept the review findings and to furnish to each other the reviews and corrective action plans. AHC IPA will maintain the Facility Site and Medical Record Review documents in the provider’s Facility Site file. The provider file includes: The Facility Site and Medical Record Audit tool* All pages of the CAP with documented deficiencies* Signed Face sheet* Signed Attestation* Evidence of correction* Correspondence and dated notations* *if done by AHC IPA or provided by the health plan DHCS CAP clarification letter dated January 21, 2003. DHCS letter dated January 21, 2003 clarified that facility sites receiving an Exempted Pass (90% or above without deficiencies in critical elements, infection control and pharmacy) will not be required to complete a CAP unless required by the Health Plan. All sites that receive a Conditional Pass (80-89% or 90% or above with deficiencies in any of the nine identified critical elements, infection control or pharmacy) will be required to establish a CAP that addresses each of the noted deficiencies. Medical Record Reviews scoring below 90% will require a CAP. A CAP may be required at the discretion of the Certified Site Reviewer. CAP notification and completion shall occur according to the following timeline: The Certified Site Reviewer will evaluate and score the Facility Site and Medical Records Review and document deficiencies on the review tool and CAP tool. Upon completion of the review, the Certified Site Reviewer will discuss the findings with the PCP/site designee at the exit interview. The PCP shall be notified of non-passing survey scores, critical element(s), infection control and/or pharmacy deficiencies, other deficiencies determined by the reviewer to require immediate corrective action, and the CAP requirements for these deficiencies. The reviewer will confirm with the PCP that all critical element(s), infection control and pharmacy deficiencies require correction within ten (10) business days. The reviewer shall explain that the PCP/site designee signature on the CAP Notification acknowledges receipt of the CAP and agreement to comply with designated timeframe. Compliance level categories for both the facility site review and medical record review are the same as listed below: Exempted Pass: 90% or above, Conditional Pass: 80-89%, Not Pass: below 80% Sites that receive an Exempted Pass (90% or above, without deficiencies in critical element(s), infection control and pharmacy) will not be required to complete a corrective action plan (CAP) unless required by the Certified Site Reviewer or local plan collaborative.
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D.
E.
All sites that receive a Conditional Pass (80-89% or 90% and above with deficiencies in critical element(s), infection control or pharmacy) shall be required to establish a CAP that addresses each of the noted deficiencies. CAP documentation shall identify the specific deficiency, corrective action(s) needed, projected and actual date(s) of the deficiency correction, re-evaluation timelines/dates, and responsible person(s). The PCP shall note corrections on the CAP as follows: Indicate in the “Corrective Action” required column the corrective action taken. Document the date the correction was implemented. The PCP may document additional steps taken in this column. Initial the appropriate column on the CAP (by the person responsible for corrective actions). Attach evidence of correction(s) i.e. in-service sign-in sheet and agenda, invoices, forms, etc. CAP follow-up activity. Facility Site CAP verification may be accomplished by PCP submission of appropriate evidence of corrections. CAP verification may require an on-site visit 45 calendar days from date of review if evidence of corrections is insufficient or deficiency cannot be verified in writing. If the site reviewer can verify that the provider has corrected the critical element(s), infection control and/or pharmacy deficiencies, a follow-up on-site visit is not required. Medical Record Review (MRR) CAP follow-up action is scheduled at the discretion of the Certified Site Reviewer and may include the following: For MRR score < 80%, the reviewer will schedule an on-site visit to verify processes implemented. For MRR score of 80-89%, a documented Corrective Action Plan may be accepted or a CAP verification visit and focused review may be requested at the reviewer’s discretion. For MRR score of 90-100% or Exempted Pass, a CAP is not required; however, a CAP may be requested at the reviewer’s discretion. On-site CAP follow-up visits are intended to verify that processes are in place to remedy deficiencies. AHC IPA and/or health plan is responsible for the follow-up, re-survey, and closure of the CAP(s) until completion of the Facility Site and Medical Record Reviews that were conducted by AHC IPA / Health Plan. Information regarding PCP’s showing no improvement and/or noncompliance to the CAP within the defined MMCD timeframes will be communicated to the Medical Director and to the County Collaborative MMCD Medi-Cal Managed Care Health Plan. Review and acceptance of the CAP. Following receipt of the completed CAP, the Certified Site Reviewer shall evaluate and/or verify corrections to approve the CAP. CAP approval is communicated to the PCP by approval letter and to County Collaborative MMCD Health Plan through the monthly data exchange of Facility Site and Medical Record Review audit activities. If the CAP is still deficient, the Certified Site Reviewer will follow-up to assist the PCP with the CAP completion.
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Accountable Heath Care IPA Provider Policy and Procedures F.
G.
H.
Pre-contractual PCP site reviews and CAPs. New PCP and/or OB/GYN sites that receive a Facility Site and/or Medical Record Review score between 80-89%, a conditional pass, will not be considered a network PCP until the CAP is submitted and accepted. New sites scoring below 80% shall not be accepted into the PCP network until the CAP has been submitted, reviewed by the Medical Director, and accepted. Contracted Network PCP site reviews and CAPs. At the exit interview, the Certified Site Reviewer shall notify providers of non-passing survey scores, critical element(s), infection control and pharmacy deficiencies, and other deficiencies determined by the reviewer or plan to require immediate corrective action, and the CAP requirements for these deficiencies. Within ten (10) business days of the survey date: Providers shall submit a completed CAP with verification for all critical element(s), infection control and pharmacy deficiencies and/or other survey deficiencies requiring immediate correction; and The Quality Department shall provide a survey findings report and a formal written request for corrections of all other (i.e. non-critical, non-immediate) deficiencies to providers. Within 45 days of the survey date: The Certified Site Reviewer shall re-evaluate and verify corrections of critical element(s), infection control and pharmacy deficiencies and other survey deficiencies requiring immediate correction. Within 45 calendar days from the date of the written CAP request; Providers shall submit a CAP for all deficiencies (other than critical element(s), infection control and pharmacy); and The Certified Site Reviewer shall review/revise/approve CAP and timelines. Within 60 calendar days from the date of written CAP request: Providers shall complete all corrective actions; and The Certified Site Reviewer shall provide educational support and technical assistance as needed, re-evaluate/verify corrections, and close the CAP. Beyond 60 calendar days of the date of written CAP request: Providers may request a definitive, time-specific extension period not to exceed 90 calendar days from the survey findings report and CAP notification date, unless a longer extension is agreed to by AHC IPA’s Medical Director and approved by the health plan to complete corrections if extenuating circumstances that prevented completion of corrections can be clearly demonstrated. The Certified Site Reviewer shall re-survey any provider site in 12 months that required an extension period beyond 90 calendar days to complete corrections prior to closing the CAP. CAP review and acceptance. Following receipt of the completed CAP, the Certified Site Reviewer shall evaluate and/or verify corrections to approve the CAP. The PCP and/or OB/GYN will receive a formal notice of CAP approval.
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Accountable Heath Care IPA Provider Policy and Procedures
The closed CAP shall include documentation of problems in completing corrective actions (if any), education and/or technical assistance provided by the plan, evidence of the correction(s), completion/closure dates, and name/title of the reviewer.
I.
Delayed CAP submission process. If the CAP for the Critical Element(s), infection control and pharmacy deficiencies were not completed and submitted with ten (10) business days from the date of the review, a second and final Critical Element(s),infection control and pharmacy CAP request letter will be sent to the PCP. Failure to submit required documentation within 72 hours of the second notice may result in reassignment of the members. If the CAP deficiencies other than critical elements, infection control and pharmacy are not completed and submitted within the time-specific extension period, the Certified Site Reviewer will contact the PCP as a reminder that the CAP is due and discuss with the Quality Improvement (QI) Director and Medical Director the outstanding issues.
J.
Non-Passing / Non-Compliant Provider Non-Passing Pre-Contracted Provider A pre-contracted provider who scores below 80% on the full scope site review survey shall not be counted as a network provider. Prior to being approved as a network provider, a non-passing provider must be resurveyed and pass the full scope site review survey at 80% or higher. After achieving a score of 80% or higher, a CAP shall be completed as specified under CAP timeline requirements. Non-Passing Contracting Network Provider Providers shall be notified of the survey score, all cited deficiencies, and CAP requirements at the time of a non-passed survey. Any provider with as non-passing score must correct cited deficiencies which are then verified by the Certified Site Reviewer according to the CAP timelines established in this policy. If the CAP deficiencies are not completed and submitted within the time-specific period, the following process will be instituted: The Certified Site Reviewer will contact the PCP as a reminder than the CAP is due and document in the provider file. The Certified Site Reviewer shall discuss the outstanding issues with the QM Director and the Medical Director. The Medical Director will determine an immediate plan of action. In the event of continued non-compliance by the provider, upon the Medical Director’s discretion, the outstanding issues may be presented and discussed at the Peer Review and Credentialing Committee (PRCC) to recommend the next steps. Upon the discretion of the PRCC, the outstanding issues may then be presented and discussed at the Quality Management Committee (QMC) who may then make recommendations to the Governing Board. Upon the recommendations of the QMC and the determination of the Governing Board, non-compliance may result in: New members will not be assigned to network providers that score below 80%
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Accountable Heath Care IPA Provider Policy and Procedures until corrections are verified and the CAP is closed. Any provider with a non-passing score may be removed from the provider network. Plan members will be appropriately re-assigned to other network providers. Members assigned to non-passing, non-compliant providers will be given a 30day notice that the provider is being removed from the network. Other appropriate action as determined by the Governing Board. Non-Compliant Provider If the CAP deficiencies are not completed and submitted within the time-specific period outlined in this policy, the following process will be instituted: The Certified Site Reviewer will contact the PCP as a reminder that the CAP is due and document in the provider file. The Certified Site Reviewer will discuss the outstanding issues with the QM Director and the Medical Director. The Medical Director will determine an immediate plan of action. In the event of continued non-compliance by the provider, upon the Medical Director’s discretion, the outstanding issues may be presented and discussed at the credentialing committee to recommend the next steps. Upon the discretion of the credentialing committee, the outstanding issues may be presented and discussed at the QMC who may then make recommendations to the Governing Board. Upon the recommendations of the QMC and the determination of the Governing Board, non-compliance may result in: New members will not be assigned to network providers that do not correct survey deficiencies within the established CAP timelines as established in this policy until such time as corrections are verified and the CAP is closed. Any provider that is non-compliant may be removed from the provider network. Plan members will be appropriately re-assigned to other network providers. Members assigned to the non-compliant provider will be given a 30-day notice that the provider is being removed from the network. Other appropriate action as determined by the Governing Board.
K.
L
Provider Appeal Process Providers removed from the network shall have the right to appeal the decision with AHC IPA and health plan. If verified evidence of corrections is acceptable to AHC IPA and health plan and the decision is reversed, the Certified Site Reviewer shall repeat the full scope survey or accept the current survey and CAP as completed and re-survey the site in 12 months. Any non-passing and/or non-compliant provider may re-apply through the application process. All applicants shall undergo an initial Full Scope Survey and be required to adhere to the requirements and standards established by the policy. Monitoring sites between provider certification visits. AHC IPA shall systematically monitor all PCP and OB/GYN sites between each regularly scheduled full scope site review survey.
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Accountable Heath Care IPA Provider Policy and Procedures
M.
Critical element(s), infection control and pharmacy deficiencies will be followed-up every six months until two consecutive satisfactory reviews are noted. Monitoring methods may include but not limited to on-site visits, medical record reviews, quality audits, follow-up on member complaints and grievances, HEDIS audits, telephonic and/or e-mail transmittals. Focused Review A focused review is a targeted audit of one or more specific site review component and/or medical record survey component and shall not be substituted for the full scope survey. Focused reviews may be used to monitor providers between full scope site review surveys, to investigate problems identified through monitoring activities and/or member grievances, or to follow-up on corrective actions.
Confidentiality of Information Member personal identifying information or individual identifying information will be handled in accordance with AHC IPA's Confidentiality Policy and other policies, in addition to applicable state and federal laws. Any and all information shall be kept confidential. Recordkeeping The Medical Services Department is responsible for retaining and maintaining documents/drafts/records/paperwork pertaining to Facility Site and Medical Record Surveys.
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Accountable Heath Care IPA Provider Policy and Procedures Access to care and services
Purpose: To ensure that all members of Accountable Health Care IPA has availability and accessibility to providers and 24 hour care and appointments involving urgent, emergency, specialty referrals, and routine exams. Policy: All health care professionals must be available by phone outside the business hours, which includes 24 hours everyday. All providers must be available or have a designated physician-on-call for patients‘ call / emergencies occurring after regular office hours, during illness and vacations. There is access to care after normal working hours for urgent medical events that require attention after hours, which includes 24-hour physician access for members. AHC IPA does not deny, limit, or condition the coverage or furnishing of benefits to individuals eligible to enroll in a plan offered by the delegate on the basis of any factor that is related to health status (with certain ESRD exceptions regarding enrollment). AHC IPA does not refuse care and services to members just because they develop ESRD while enrolled. AHC IPA authorizes and manages members with ESRD, who are frail, disabled or near the end-of-life and/or who has a special need if it is medically necessary. A log of calls received by the answering service will be forwarded to the administrative office upon request. AHC IPA medical director is also on call in the event the member’s PCP is not available to take the calls. Members will have access to care according to standards below: 1. Telephone Access- is defined as the number of seconds/ minutes until a live person answers the telephone and who can answer a member’s questions.(including behavioral health care member) It is the policy of the Accountable Health Care IPA for telephone calls to be answered by a live person within 30 seconds and respond within 3 minutes. Abandonment rate will be less then 5 %.
Telephone access for member services - AHC IPA has process in place to provide access to staff for providers and members seeking information about the Utilization Management process and Utilization Management decision.
2. Routine or Non-urgent Care - Appointments for a complete physical exam is within 10 business days. For children under 2 years old, initial health assessments are done according to the guidelines from the American Academy of Pediatrics. It is generally scheduled in line with the child’s immunization schedule.
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Accountable Heath Care IPA Provider Policy and Procedures 3. Non-Urgent Symptomatic Exam - Appointments for a non-urgent symptomatic exam is within 7 calendar days. 4. Advance Access - Appointments with a primary care physician, or other qualified primary care provider such as a nurse practitioner or physician’s assistant, within the same or the next business day from the time an appointment is requested, and advance scheduling of appointments at a later date if the member prefers not to accept the appointment offered within the same or the next business day. 5. Urgent Exam - Urgent care appointments for services that do not require prior authorization: within 48 hours of request of appointment. Urgent care appointments for services that require prior authorization: within 96 hours (4 calendar days) of request of appointment 6. Emergency Exam - Emergency exams are to be handled immediately at either the Urgent Care Department or the nearest emergency room. 7. Specialty Referral - A specialty referral is defined as an non-urgent appointment with a specialist from the time the Primary Care Provider requests the referral. A specialist is defined as a provider who is not responsible for primary care. Specialty referral appointments are made within 15 business days of PCP referral/TAR authorized date. 8. Pregnancy Referral - initial prenatal visit is done within 7 calendar days. Maternity patients in the 1st trimester will be seen within 2 weeks. Maternity patients in the 2nd trimester will be seen within 1 week. Maternity patients in the 3rd trimester and high-risk patients will be seen within 3 working days. For all urgent situations in the pregnancy, the patient will be seen within 24 hours. 9. Preventive Care (Non-urgent Asymptomatic Exam) – within 30 calendar days. For Medicare patients, within 20 calendar days. For Care 1st members, 1st prenatal appointment within 7 days 10. Initial Health Assessment – 120 days from the date of enrollment for all members. 11. Ancillary Services:-Non-urgent care appointment for ancillary services for the diagnosis or treatment of injury, illness, or other health conditions within 15 business days of request of appointment 12. Waiting time in office to see physician – The time spent by the patient before actual contact with the physician. A patient with an appointment must be seen within 30 minutes. 13. After Hours Care – A system to provide 24-hour access to Physician. Contracted PCPs are required to have 24-hour on call coverage for AHC IPA members for easy access even after office hours. After hours call at AHC IPA is managed by a telephone system or answering service. After hour answering service or telephone system will instruct members that if they feel they have a serious acute medical condition, they should seek immediate care by calling 911 or going to the nearest emergency room.
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Accountable Heath Care IPA Provider Policy and Procedures Access to care after normal working hours for urgent medical events is handled by on-call physicians. Physicians must answer the call within 30 minutes. Members can go directly to urgent care centers or to the nearest emergency room. 14. Sensitive Services – Sensitive services relate to those conditions that are sexually transmitted, such as Chlamydia, Gonorrhea, Syphilis, AIDS. Members can access these services within 24 hours but not less than 48 hours of request. 15. Behavioral Health Care – Member with a life-threatening emergency will be seen immediately. Member with a non-life-threatening emergency will be seen within 6 hours. Urgent care will be provided within 48 hours and routine office visit will be provided within 10 working days Monitoring and Evaluation: 1.
Access to care is monitored through member surveys and member complaint tracking.
2.
Access Studies are conducted each year, which focus on appointment scheduling and waiting time using the Access to Care Guidelines. Performance is measured for compliance with the guidelines.
3.
Access and availability studies are included as an ongoing part of the Annual Quality Management Work Plan.
4.
If opportunities for improvement are identified, a decision is made as to which opportunity to pursue.
5.
Interventions are implemented to improve performance resulting in guideline compliance.
6.
The effectiveness of the interventions is evaluated. Additional telephone or mail surveys may be conducted to further evaluate a particular problem (e.g., accessibility for after-hours telephone consultation).
Reporting and Follow-up: 1.
Results of the monitoring and evaluation are communicated to staff and providers through newsletters, memos and other media. Education is provided as appropriate.
2.
The findings of monitoring and evaluation and action(s) taken, as indicated, are reported to the Quality Management Committee and the Governing body. Recommendations for further action are made and follow-up is carried out as directed until the issue is resolved.
3.
Tracking and trending reports are submitted to the Quality Management Committee and the Governing body at least on an annual basis.
4.
If need arises, AHC IPA will contract new PCP/specialist in the area
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Accountable Heath Care IPA Provider Policy and Procedures
Waiting Time Audit Procedure: Complete forms for all the Physician’s appointments for one day’s schedule. At least six (6) forms for patients who are not more than 15 minutes late must be fully completed. If a patient arrives greater than 15 minutes late, exclude this patient from the sample. Exclude health evaluations and new patient appointments. If at least six (6) forms are not fully completed in one day’s schedule, continue on the next day’s schedule until at least six (6) forms are fully completed. Do not give the forms to patients to complete. All entries are to be made by staff and physicians. Receptionist: The person who signs the patient in will write in the designated area the following: Name of the Physician the patient is seeing Date of visit Time patient checked in Appointment time Then the audit sheet should then send with the chart. Nurse/Medical Assistant: The Nurse/Medical Assistant will write in the designated area: Time patient was checked into the exam room The Physician: The Physician will write in the designated area: Time patient was seen by the Physician Comment field may be used by Providers or staff for comments, i.e. emergency at hospital (if Provider is late), patient arrived late, etc. All completed Waiting Time Audit Sheets should be forwarded to the Receptionist who will review the results and exclude patients who are more than 15 minutes late for their appointment. Please forward completed audit sheets to: QM Department Accountable Health Care IPA 2525 Cherry Ave, Suite 225 Signal Hill, CA 90755
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Accountable Heath Care IPA Provider Policy and Procedures
Patient Waiting Time Survey
*** Your Time is Important To Us*** PCP/ Provider:
______________________________________________
Date:
________________________
Appointment Time:
am
_________ pm
__________
Patient Arrival Time:
am
_________ pm
__________
Into Exam Room
am
_________ pm
__________
Seen by PCP/ Provider
am
_________ pm
__________
Comments:
______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________
Please return this form to the Receptionist/ Office Manager for collection.
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ACCESS STUDY METHOD OF DATA COLLECTION
Select the method by which you completed the Access Study from the following:
1.
A representative sat in the provider’s office and observed the waiting times for phone access and to check the appointment book to ascertain the number of days it took to secure an appointment. Yes
2.
A representative called a provider and pretended to be a patient to determine the number of days it took to get an appointment. Yes
3.
__________
AHC IPA requested the provider office personnel to fill out the study and send it back to the group. Yes
5.
__________
A representative called a provider, identified his/her affiliation and stated that he/she was attempting to determine how long it would take to get an appointment. Yes
4.
__________
__________
Other. Please describe briefly how you completed the study. ________________________________________________________________________ ___________________________________________________________________
__________________________________ Signature
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Accountable Heath Care IPA Provider Policy and Procedures
Medical Office Standard Purpose: To set forth minimum requirements for a contracted Primary Care Providers/Medical Group’s physical plant according to Title 22 / DHCS guidelines. The following requirements meet Title 22 regulatory requirements that are mandatory. Each PCP site will be evaluated at least annually by AHP IPA and/or the California Health Care Services according to requirements stated below. (Ref. Facility Site Review tool) Policy: 1. There is convenient, adequate parking, some of which must be accessible to handicapped persons. 2. The facility is neat, clean, and well organized. Adequate storage space is available so that patient care areas are not unnecessarily cluttered. All electrical wiring is covered and concealed according to building codes. Incandescent bulbs and fluorescent tubes are covered. Floors, walls and ceilings are in good repair. Lighting is adequate. 3. Waiting areas have sufficient floor space and seating capacity to accommodate the typical patient load. a) Children and obstetrical patients are separated wherever possible. b) Plan and non-plan patients are not differentiated by providing separate waiting areas or entrances. 4
The number of examination and treatment rooms is adequate (minimum two) to accommodate patient's needs.
5
There is at least one exam room, which is maintained for patients with contagious or infectious diseases.
6
The number of adult, pediatric and obstetrical examination tables is adequate to meet patient needs.
7.
Exit signs and evacuation map must be appropriately posted
8.
Fire extinguisher should be present, easily accessible and recharged annually
9.
Hallways, doorways and exits are free of obstructions.
10. Regular trash can should have covers. Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures 11. Needles, syringes and prescription pads should not be accessible to the members. 12. CLIA waiver certificate should be available if drawing blood. (CLIA certificate if performing lab tests) 13 The provider's hours of operation and emergency telephone number are clearly indicated on signs posted on or near the main entrance
If the group's entry area or parking lot are protected by a gate when the facility is closed, hours of operation and the emergency telephone number are shown on a sign posted on the gate. Adequacy of space and parking will be monitored periodically. Policies and procedures for housekeeping must be maintained. These include specific responsibilities of personnel and a procedure for regularly monitoring completion of specified tasks.
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Accountable Heath Care IPA Provider Policy and Procedures
Infection Control
Purpose: Health care workers are posed to a wide variety of infectious agent in the blood and saliva of the patients they treat. It is the purpose of this protocol to minimize the risk of transmission of disease to the health care workers, their family and patients. Policy: a. b. c. d. e. f.
Autoclave is maintained in good working condition. Spore testing is performed monthly. Expired sterilized instruments are inaccessible to the provider. Antimicrobial hand washing agents are easily accessible. Infectious wastes are disposed of properly. Proper attire, gloves, mask and protective eye wear should be worn while handling patient (according to guidelines). g. Current State, Federal, CDC and OSHA guidelines should be followed for infection control procedures. Important notes: a. b. c. d. e. f.
Always wear coat/lab jacket when treating patients. Always wash hands before and after every patient contact. Always wear gloves when treating patient, drawing blood, etc. Dress and groom appropriately. No excessive jewelry. Change paper roll from examination table after patient has been discharged. Each examination room should be cleaned with disinfectant (e.g. 10% bleach) after patient has been discharged. g. Autoclave all instruments. h. Use cold sterilization for glass thermometer. i. Follow biohazardous waster protocol. Infection control section consist ofa. b. c. d. e.
Hand washing Cold sterilization Thermometer Autoclave Biohazardous waste
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Accountable Heath Care IPA Provider Policy and Procedures HANDWASHING: I
When to wash a. b. C. d. e. f
2.
Before coming on duty Before and after direct or indirect patient contact. Before and after performing body functions, such as blowing the nose or going to the toilet. Before and after preparing instruments for autoclave. Before and after dressing change, drawing blood, or catheter insertion. Must use Parachlorometaxylenol before and after any invasive procedures.
How to wash. a. b. c. d. e. f. g
Apply proper amount of soap to the hand. Work up lather by vigorously rubbing your hands together, fingers intertwined. When necessary, use scrub brush, scrub for at least 15 seconds over every part of hands, including between knuckles and over the wrist. Rinse hands by placing them under warm running water. Pont your finger tips upward. Do not touch the side of the sink or faucet while rinsing. Dry hands with paper towel. Use the elbow/foot pedals to shut off faucet. If faucet has round know, then use paper towel to shut off water.
COLD STERILIZATION: 1.
2. 3. 4.
5. 6. 7. 8. 9.
Only activated high-level disinfectant that eradicates HIV/HB/TB is used according to product label instructions. Two percent (2%) glutaraldehyde or three percent (3.1%) glutaraldehyde (e.g. cidex, cidex plus, wavicide, sterrel) are acceptable sterilants, or any EPA approved sterilants are acceptable. Date of expiration must be noted on the container (e.g. solution may be used for 14 days or 30 days after activation). Activated solution poured in a container should also be labeled with name of solution and date of expiration. OSHA labeling requirements should be met. Instruments must be submerged completely in the solution for a minimum of 10 hours. Container should be covered and temperature of the solution should be at least 20 degree centigrade Remove instruments from sterilant using sterile technique and rinse thoroughly with sterile water. Wear gloves for this procedure. Dirty instruments should be cleaned in running water and try to avoid scrubbing the instruments. Any time that the glutaraldehyde (cidex, waviced, etc.) solution appears dirty or cloudy, the solution considered is ineffective and must be changed. Disinfectant solutions will be kept covered and used in well-ventilated areas.
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Accountable Heath Care IPA Provider Policy and Procedures THERMOMETER: 1. Oral and rectal glass thermometers are handled and stored in separately labeled containers. 2. Disposable plastic sheets are used on all thermometers. 3. Glass thermometers must be cleaned and disinfected after each used, even if plastic sheath is used. 4. Cracked, chipped, or broken thermometers should be discarded immediately. Procedure: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Wash hand with water and soap. Remove thermometer from holding container. Rinse with sterile water. Apply temp away sheath. Take temperature (oral or rectal). Remove temp away sheath and discard in a container lined with red plastic bag (Biohazard). Read the temperature and document in the chart. Clean thermometer after each use by washing them in water and cleanser (e.g. green soap). Rinse and rough dry thermometer. Shake thermometer to 96 degree F. Immerse thermometer in storage container filled with 2% glutaraldehyde for at least 30 minutes. Transfer the thermometer to holding container filled with 2% glutaraldehyde (e.g. cidex, wavecide). Change solution every 2 days. (if solution is dirty or cloudy, change immediately)
Note: 70% to 90% Ethyl alcohol is acceptable as disinfectant for glass thermometer. AUTOCLAVE: 1. Autoclave (steam sterilization), chemiclave (chemical sterilization) or dry heat sterilization method is used for all instruments which are utilized for invasive procedures. 2. All instruments should be bagged. 3. All bags must have indicator tap. Date of sterilization and date of expiration. 4. All sterilized instruments are good for 30 days. 5. A log must be maintained for each sterilization cycle (see attached log). 6. Spore testing must be done monthly. 7. Result of the spore testing should be filed and kept for one year. 8. Autoclave should be cleaned monthly (preventive maintenance) according to manufacturer's direction. 9. Autoclave maintenance log should be kept for one year. 10. Autoclave should be calibrated annually and record must be maintained. 11. Disposable items should not be sterilized. 12. Disposable sterile pre packed instruments are good for indefinite period unless package is opened, damaged or wet or manufacturer has expiration date on the package.
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Accountable Heath Care IPA Provider Policy and Procedures Technique for Autoclaving: 1. 2. 3. 4. 5. 6. 7. 8.
Wear general-purpose rubber gloves. Rinse instruments in running water. Check for any debris. If any instruments are not cleaned then only scrub with brush. Rinse again. Dry instruments with towel. Bag instruments and seal. Apply indicator tap. Load instruments in a chamber such that steam can penetrate to all bags. DO NOT OVERLOAD. Close chamber and start. Temperature, pressure and total cycle time should be according to manufacturer's requirement. Write date of sterilization and date of expiration on the bag. Check all bags for proper sterilization (i.e. tap colored changed, bags are not torn, no moisture and properly sealed). Do not REUSE bag.
9. 10. 11. 12. 13.
Technique for Spore Testing: 1 2. 3. 4. 5. 6.
Put killet ampule or Dry Test Strip in between instrument bags in the center of the chamber.(in between the bags of instruments) Turn autoclave on and run full cycle. Take out ampule or dry test strip from the autoclave and send to Laboratory. Also send a control ampule or control test strip to the Lab. When result comes, file it. If test result is positive, DO NOT USE AUTOCLAVE. Recall all goods dated past last negative spore test. Clean autoclave with appropriate cleanser. Return spore test, if second test is POSITIVE, have the autoclave serviced.
7.
Resume autoclave only when spore test is NEGATIVE.
NOTE: Killet ampule contains live bacteria. They should be stored in refrigerator at 35 degree F – 45 degree F Killet ampule should not be stored with food or biological. It is recommended to have additional autoclave or to use cold sterilization procedure in the event of malfunction of autoclave. BIOHAZARDOUS WASTE:
Biohazardous waste includes: 1.
Laboratory waste
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2.
Accountable Heath Care IPA Provider Policy and Procedures A material that has come in contact with pathologic specimens, including human tissue, blood, excretions and disposable material with secretions which contain etiologic agent.
3.
Any material believed to be contaminated with etiologic agents.
Handling and disposal of waste: 1. 2.
3. 4. 5. 6. 7. 8. 9. 10. 11.
12. 13.
Treatment room, laboratory area and examination room (OB-Gyn) have both regular waste can and biohazardous waste can. All biohazard waste cans are a step on variety and contain a red plastic bag liner. Waste can should be labeled "biohazardous waste" in English and Spanish with international symbol. Needles, syringes, and sharps will be disposed of directly into a puncture resistant container. Needles must not be bent, broken or recapped. Recapping of a needle increase the risk of unintentional needle stick injury. When container is 3/4 fill, it will be sealed to preclude entry and placed in designated secured area for proper disposal. Sharp container must not be accessible to patients or any other unauthorized personnel. Sharp container should not contain any gauze, cotton balls or gloves. Blood or other bodily secretions will be cleaned up immediately with 10% household bleach or any EPA approved sterilant. Personal protective equipment must be used where there is potential for contact with contaminated sources and fluids. Universal precautions are practiced at all times. Exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials must be performed. A list of job classifications in which employees may have occupational exposure will be maintained. All personnel at risk for occupational exposure to blood-borne pathogens will be offered Hep B vaccine and necessary boosters. Biohazardous waste must be secured in a locked area, in leak-proof containers, with tight-fitting covers marked "Biohazardous Waste" with international biohazard symbol. Area where biohazard waste is stored must be marked with: CAUTION - BIOHAZARDOUS WASTE STORAGE AREA. UNAUTHORIZED PERSONS KEEP OUT
14.
15. 16. 17.
Biohazardous waste must be transported separately from non hazardous waste. Biohazardous waste should be transported only by the hauler registered as hazardous waste hauler by the Department of Environmental Services. There is evidence of a contract with a licensed medical waste hauler. All employees will be trained on infection control and blood-borne pathogens. Records of inservice training must be kept in the employees’ files.
NOTE:
State law allows for storage of biohazardous waste: At 32 degree F or 0 degree C for 30 days Below 32 degree F for 90 days.
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Accountable Heath Care IPA Provider Policy and Procedures
OSHA – Blood Borne Pathogen Standard
Purpose: To help employees understand and deal with chemical hazards to which they may be exposed during the course of their employment. Policy: The program components are: 1.
List of Products. Determine the identity of chemicals or hazardous substance used in the clinic. A list of these chemical must be prepared.
2.
Labeling. a.
Ensure that the labels are affixed to all the chemical containers.
b. c
Containers properly labeled by the manufacturer do not need additional labels. All labels should contain: i. ii. iii.
3.
The identity of the chemical Appropriate hazard warnings. Name and address of manufacturer or other responsible party.
MSDS (Material Safety Data Sheets) Manufacturers and suppliers are required to provide MSDS for their products if they contain hazardous chemicals. If not supplied, employer is obligated to request from the manufacturers and suppliers. Maintain a file of all MSDS. It should be available to the employees. File should be kept up-to date.
4.
Develop and implement written hazard communication program for the clinic.
5.
Training. Employer must provide training for employees both at the time of their initial assignment and whenever a new hazardous material is introduced into their workplace, and whenever procedure for safe handling and emergencies are modified. Training should make clear to employees the hazards of the chemicals and handling, the operation where hazardous chemicals are present, the location and availability of the written hazard communications program, including the list of chemicals, measures to prevent exposure, an explanation of the labeling and MSDS requirements, and an explanation of the OSHA rule. This can be done through continuous education, staff meetings and discussions and/or audiovisuals.
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Accountable Heath Care IPA Provider Policy and Procedures 6
Employer must offer Hepatitis B vaccine to all employees free of charge. Vaccine documentations should be in employees file. If employee refuses to take the vaccine, it must be documented and signed by the employee.
Category I The following list identifies all the job classifications in which employees have occupational exposure: ¾ ¾ ¾ ¾ ¾
Physicians/ Physicians Assistants (who provide direct patient care) Nursing Supervisors Nurses (R.N., L.V.N. ) (who provide direct patient care) Medical Assistants/Phlebotomists Technicians/Technologists (Radiology, Orthopedic)
The following is a list of tasks and procedures in which occupational exposure (contact with blood, body fluid, tissue, non-intact skin, or skin lesions) occurs and that are performed by the above employee: 1. Applying pressure to control bleeding 2. Performing or assisting with invasive procedures in Exam/Procedure room 3. Venipuncture (Starting IV, blood drawing) 4. Discontinuing IV 5. Tubing change at hub of IV catheter 6. NG tube insertion 7. NG tube irrigation/aspiration 8. NG tube removal 9. Rectal temperature 10. Inserting rectal suppository 11. Enema 12. Removal of fecal impaction 13. Ostomy care/irrigation 14. Clean up of emesis 15. Clean up of incontinent patient: urine/feces 16. Urinary catheter insertion/irrigation/removal 17. Insertion of vaginal suppository 18. Vaginal irrigation 19. Wound irrigation 20. Wound/orifice packing and removal 21. Laceration care 22. Clean up of amniotic fluid 23. Suture removal/draining of wound 24. Assisting with irrigation and drainage of abscess 25. Oral suctioning 26. Tracheostomy care 27. Specimen processing (collection and handling) 28. Emptying foley bag, urinal, bed pan, emesis basis Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures 29. Spill cleanup-blood, amniotic fluid, other body fluids 30. Changing visibly soiled examination table covers 31. Blood drawing via: intravascular line/fingerstick/heelstick Category II The following list identifies all job classifications in which employees have occupational exposure: ¾ ¾ ¾ ¾ ¾
Facility managers Medical records clerks Receptionists Health Educators Case Managers Housekeeping Director of Nursing Security
The following is a list of tasks and procedures in which occupational exposure occurs and that are performed by the above employees: 1. Assisting with invasive procedures in exam/procedure room 2. Routine vital signs 3. Giving medications: oral, IM, IV, 4. Applying restraints/protective devices 5. Physical assessment 6. Applying topical medication 7. Dressing removal 8. Dressing change and dry wound care 9. Suture removal, clean dry wound 10. Dipstick urine checks 11. Placing oxygen mask/prongs/cannula Methods of Compliance 1. General: Universal precautions shall be observed to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible all body fluids shall be considered potentially infectious materials. 2. Engineering Controls: An engineering control is the use of available technology and devices to isolate or remove hazards from the worker. Examples of engineering controls used in Category I and Category 11 job classifications include but are not limited to: puncture resistant sharps containers, splash guards, and hand washing facilities.
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Accountable Heath Care IPA Provider Policy and Procedures 3. Work Practice Control: Work practice controls are alterations in the manner in which a task is performed in an effort to reduce the likelihood of a worker's exposure to blood or other potentially infectious materials. Methods: a.
Hands shall be washed with an appropriate germicide after removing gloves or as soon as possible after contact~ with body fluids. All personal protective equipment (PPE) should be removed immediately, or as soon as possible upon leaving the work area, and placed in an appropriately designated area or container for decontamination, or disposal. Used needles and other sharps shall not be sheared, bent, broken, recapped, or resheathed. All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, or exposure.
b.
C. d.
4. Personal Protective Equipment: Personal protective equipment is specialized clothing or equipment used by workers to protect themselves from direct exposure to blood or other potentially infectious materials. Personal protective equipment includes but are not limited to: a. b. C. d.
Gloves Gowns/aprons/head and foot coverings Masks Eye protection/Face shields
Equipment and Environmental Management 1.
General Housekeeping: The work site will be maintained in a clean and sanitary condition. Appropriate cleaning schedules for rooms where body fluids are present will be determined and implemented. Schedules shall be as frequent as necessary depending on the type of surface to be cleaned, and the amount and type of soil present. Nursing staff will wear personal protective equipment appropriate including general-purpose utility gloves during all cleaning of blood or other potentially infectious materials and during decontaminating procedures.
2.
Decontamination: a.
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Contaminated surfaces, equipment and reusable items shall be decontaminated with an appropriate germicide immediately or as soon as feasible after contamination. Page 4 of 6
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Accountable Heath Care IPA Provider Policy and Procedures b.
All bins, pails, cans, and similar receptacles intended for reuse shall be inspected and decontaminated on an as needed basis.
NOTE: 10% household bleach is the most economical and effective solution for decontamination 3.
Waste Management: Regulated waste shall be contained, handled, and discarded in a manner which protects the employee from exposure and is in accordance with Waste Management Policies.
Exposure Categories and Definition There are several factors, which must be considered in identifying a "significant exposure" that may put the health care worker at risk for disease. In each situation, it is important to identify: 1. 2. 3. 4. 5.
The TYPE of exposure The LENGTH of the exposure The length of TIMES SINCE the exposure The SOURCE of the exposure The HEALTH of the employee, i.e. immune status
The following categories are intended to provide guidance and examples. They do not include every possible situation, but do not provide a breadth, which depicts typical blood and infectious body fluid exposures. -INFECTIOUS BODY FLUIDS INCLUDE: semen, vaginal secretions, amniotic, peritoneal, synovial, pleural, cerebro-spinal, pericardial fluids, saliva and any fluid containing visible blood. Massive Exposure: A massive exposure includes: 1.
Any injection of blood or infectious body fluid
2.
A transfusion of infected blood
3.
A large skin surface area exposure for more than five (5) minutes.
Example: Emergency invasive procedure/surgery when protective clothing was either ineffective or not donned. Definite Parenteral Exposure: A definite parenteral exposure includes: 1 Any intramuscular, subcutaneous, intradermal needle stick from a needle contaminated from patient use. 2. Any blood or infectious body fluid soaked clothing in contact with non-intact skin. Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures 3.
Any laceration or abrasion from contaminated instruments or equipment.
Possible Exposure: Any splash to a mucosal surface, i.e. eyes, nose, mouth It is particularly important to assess the quality of infectious body fluid Involved in the splash, as well as the length of time the mucosal surface was exposed. Doubtful Exposure:
1
Any needlestick from a needle that has NOT been in direct contact with any blood or infectious body fluid, e.g., "piggyback" IV, etc.
2. MINIMUM cutaneous exposure to intact skin.
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Accountable Heath Care IPA Provider Policy and Procedures
Fire & Earthquake Safety Purpose: To assure maintenance of minimum fire and earthquake safety within contracted PCP offices. Policy: 1. The facility is maintained in compliance with all applicable local, state and federal fireand general safety requirements. 2. The facility has a current fire inspection certificate issued within the preceding twelve months indicating that acceptable local standards are met. 3
Exit signs are clearly visible and appropriately located.
4. Emergency evacuation maps are easily readable and appropriately located in hallways and in all exam rooms. 5. A written emergency evacuation plan is maintained. The plan includes specifications for staff members with responsibility for evacuating patients and staff and on how to notify fire or police. 6. Fire extinguishers are regularly inspected (i.e. once every twelve months) and readily accessible to staff. 7. Covered containers are used for regular (non-infectious) waste.
Procedure: 1
Fire inspections are scheduled once every twelve months. A central file of certificates and correspondence regarding these certificates is maintained.
2.
Inspections of fire extinguisher(s) are scheduled once every twelve months. A current file related to these inspections is maintained. Current inspection tags are securely attached to extinguishers.
3.
Regular reviews of fire safety features (e.g., exit signs, evacuation maps) are scheduled.
4.
The written emergency evacuation plan is discussed in new employee orientation and is readily accessible to all staff. The plan is regularly reviewed and updated to reflect changes in the physical plan, changes is safety codes, etc.
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Accountable Heath Care IPA Provider Policy and Procedures RESPONSE TO FIRE:
Sound the alarm either with the pull alarm station or telephone If using the telephone, give the location and extent of the fire Warn others near you Check doors before opening for heat, if hot, do not open Open doors slowly and be prepared to close doors quickly Evacuate all patients and other employees who are in immediate danger If you have time and there is no immediate danger, close all windows and doors in the area. Do not use elevators Above all, remain calm
EARTHQUAKE SAFETY:
Assign a responsible person to coordinate response to an earthquake Move away from windows and glass Take cover under a sturdy desk, table, or brace yourself in a doorway After the quake, assess damage, check others around you for injury Provide first aid if qualified
Follow instructions to move patients and/or evacuate the building. Supervisor must assured that all employees / patients are evacuated ay the safer place and then lastly he / she should evacuate.
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Accountable Heath Care IPA Provider Policy and Procedures
Patient Emergency
Policy: In the office setting, urgent/emergent care should be provided by the PCP or the on call designee. If medically necessary, the patient should be transferred to an urgent care center or hospital emergency room as appropriate. The PCP or on call physician designee is required to be available 24 hours/day, seven days/week. Procedure: The physician or the Registered Nurse/Physician Assistant on duty is responsible for triaging emergent/urgent patients in the office. 1. 2.
3. 4.
Perform a visual assessment of the patient, inquire about the presenting complaint and ask follow-up questions regarding the nature of the complaint. Document and record the vital signs of the patient (taken by nurse, or his/her designee), including pulse, respiration, temperature, blood pressure, and in appropriate cases, height and weight. Communicate abnormal findings to the nurse and the physician immediately. Emergent patients and/or those with abnormal vital signs should be placed in an exam room immediately and the provider should be notified.
Urgent patients also must be observed and have their vital signs taken. Urgent patients may have abnormal vital signs, but their general condition does not require the immediate intervention of a provider. Urgent patients may, based on-their condition, be taken to the exam room for the next available provider. Non-urgent patients are seen on a first come, first serve basis, unless presenting for a scheduled appointment. Their first come, first serve status is subject to interruptions by emergent or urgent patients. MEDICAL EMERGENTY - PRIMARY CARE FACILITY 1 2. 3. 4.
If a medical emergency occurs anywhere in the primary care site, a physician should be summoned immediately by calling "code blue (or other designated terminology) in room The physician who arrives first will determine the need for Basic Life Support and /or Emergency Medical Services (EMS). Dial 911 if EMS is required. If a physician is not readily available, the highest ranking medical personnel should determine the need for CPR and EMS. Mid-level Practitioners (Physician Assistants, Nurse Practitioners) are not permitted to administer advanced cardiac life support techniques whether alone or under the supervision of a physician. They may, however, administer basic life support (BLS) techniques and perform the following:
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Accountable Heath Care IPA Provider Policy and Procedures
- Start IV with solution of normal saline - Administer oxygen - Oral airway 5.
The following basic emergency medical supplies and equipment must be available in all facilities: Benadryl 50 mg/ml Adrenaline 1: 1 000/cc Nitrostat 1/150 gm (0.4 mg) Solu-Medrol 40 mg/1 cc Mix-o-Vial Airways - 3 sizes (small, medium, large) Pediatric and adult ambu bag
EMERGENCY TRANSPORTATION 1
If a patient in a facility has a medical emergency requiring hospitalization, the attending physician must arrange ambulance transportation by a licensed ambulance company to the nearest emergency room.
2.
If there is no contracted emergency transportation service and emergency transportation is needed, dial 911 or other local emergency number to obtain ambulance service.
3.
The receiving hospital will call for authorization upon patient arrival.
Note: Emergency kit content list should have name of the medication and expiration date. Emergency kit must be inspected monthly
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Accountable Heath Care IPA Provider Policy and Procedures
Storage of Medications
Policy: All medications, including vaccines, used at provider sites shall be stored, handled, and administered according to the regulations set forth by the California Department of Health Care Services. AHC IPA will evaluate all PCP sites according to DHCS guidelines (refer to Facility Site Audit tool) Procedure: 1. Each site shall maintain and periodically update a set of internal medication/pharmacy policies and procedures. 2. All medications shall be stored in their original containers. This does not apply to cleaning or antiseptic solutions, which may be poured into other dispensing containers. 3. Germicides, disinfectants, test reagents and household cleaning substances shall be stored separately from medications. 4. All multi-dose vials shall be labeled with the date they are originally opened and discarded after one month of opening or at the expiration date, whichever come first. 5. All medications shall be discarded, per Title 22 requirements, when they reach their expiration date. 6. Medications shall be stored in a segregated manner according to their route of administration, i.e., oral, injectable, topical. 7. All medications, needles, and syringes are to be stored in an area accessible only to authorized personnel. 8. Medications shall be stored at temperature levels specified by the manufacturer (i.e. room temperature, refrigerated at 35 degrees F - 45 degrees F or frozen at less than 7 degree F 9. Controlled substances (schedule II and IV) are to be stored separately from other medications. Controlled substances shall be inventoried, logged, and controlled. This shall be the responsibility of a licensed person. Controlled substances are always stored in a locked area. 10. Medications shall be prepared in a designated clean area. 11. Daily refrigerator temperature log will be kept. 12. Sterile saline and water must be labeled with date and time when opened and discarded 24 hours after opening. 13. The use and/or dispensing of sample medications are discouraged. If a provider elects to use and/or dispense sample medications, they shall meet the following standards:
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Accountable Heath Care IPA Provider Policy and Procedures
SAMPLE MEDICATIONS POLICIES: a. b. c. d.
A physician or pharmacist shall be responsible for the storage, inventory, and dispensing of sample medications. Only a physician or pharmacist shall dispense sample medications. This cannot be delegated to other office staff. Sample medications shall be logged when received, including the medication name, quantity, manufacturer name, lot number, and expiration date. Perpetual inventory should be kept with the dispense date, name of the patient and quantity given
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Accountable Heath Care IPA Provider Policy and Procedures
Reporting Abuse
Purpose: To establish a standardized process to ensure that all cases of abuse are reported as per guidelines. Policy: It is the policy of AHC IPA to comply with the California Department of Health Services and the California Legislature Health and Safety Codes reporting guidelines regarding the following reportable cases:
Child abuse Adult abuse Elder abuse Domestic violence Injuries by Deadly weapon or criminal act (including domestic violence) Other cases deemed reportable by California DHS
Child Abuse: All health professional should report suspected or known child abuse/neglect to the child protective agency immediately by telephone. (Child protective agency is a county welfare or probation department or a police or sheriff department). A written report must be submitted within 36 hours of receiving the information regarding the incident. “Suspected Child Abuse Report form” (SS 8572) from Department of Justice, should be completed and mailed to child protective agency. All employees (including mandated reporter*) must sign a statement attesting the understanding of their child abuse reporting obligations.(CA Penal code 11166.5) Signs of Child Abuse: A.
Physical Abuse 1.
2. 3. 4.
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An unexplained or repeated injuries such as welts, bruise, that have a regular pattern resembling the shape of an article which might have been used to inflict the injury. Burns that appear to be from a cigar or cigarette especially on the soles of the feet, palms, back or buttocks; patterned burns and immersion burns. Abrasions such as rope burns or lacerations especially on the wrists, ankles, torso, palate, mouth, gums, lips, eyes, ears, or external genitalia. Fractures, many times at different stages of healing to the skull, ribs or long bones. Page 1 of 5
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Accountable Heath Care IPA Provider Policy and Procedures 5. 6.
Injuries that are in the shape of an object. Injuries not likely to happen given the age or ability of the child, such as injuries to the abdomen, kidney, bladder or pancreas, intestinal perforation, ruptured liver, spleen or blood vessels; or intramural hematoma of the duodenum or proximal jejunum. Disagreement between the child’s and the parent’s explanation of the injury. Unreasonable explanation of the injury. Symptoms of suffocation or chemical abuse. Obvious neglect of the child (dirty, undernourished, inappropriate clothes for the weather, lack of medical or dental care). Fearful behavior.
7. 8. 9. 10. 11. B.
Emotional – Verbal Abuse 1. 2. 3.
C.
Aggressive or withdrawn behavior. Shying away from physical contact with parents or adults. Afraid to go home.
Sexual Abuse 1. 2.
D.
Child tells that he/she was sexually mistreated. Child has physical signs such as: Difficulty in walking or sitting. Stained or bloody underwear. Genital or rectal pain, itching, swelling, redness, or discharge. Bruises or other injuries in the genital or rectal area. Attenuation or distortion of the hymen. An alteration of anorectal tone. Evidence of sexually transmitted disease Pregnancy
Neglect
History of lack of appropriate well-child care Failure of a child to thrive Malnutrition, untreated medical conditions, poor hygiene, rampant dental carries, excessive masturbation, aggressive behavior, excessive household responsibilities for age including child care, poor school performance, discipline problems, impaired personal problems.
Diagnosis: A thorough health assessment must be conducted by the physician, which includes a history, physical examination and developmental assessment on a child who may be a victim of abuse.
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X-Rays, CT Scans, Bone Scans or other laboratory studies are of use in determining and defining the current trauma, previous traumas, and other medical conditions. The following diagnostic process should be performed: a. Assessment of the child’s immediate medical needs b. Compilation of the past medical and social history of the child and family members. c. Assessment of the plausibility of the history being provided in light of preexisting medical conditions. d. Determination of how great a risk it would be if the child returns home. Reporting: A report must be made immediately, or as soon as possible by telephone to a police or sheriff’s department, a county probation department or a county welfare department. Within thirty-six hours of receiving information regarding the incident, a written report must be forwarded. Immunity: No mandated reporter who reports (including taking photographs) a known or suspected instance of child abuse or neglect shall be civilly or criminally liable for any report required or authorized by law. (Cal. Penal code 11172(a), (b).) Any other person reporting a known or suspected instance of child abuse or neglect (including taking photographs) shall not incur civil or criminal liability as a result of any report authorized by law, unless it can be proven that a false report was made and the person knew that the report was false or made with reckless disregard of the truth or falsity of the report Penalty: Any mandated reporter who fail to report an incident of known or reasonably suspected child abuse or neglect as required by the reporting laws, is guilty of misdemeanor punishable by up to six months confinement in a county jail or by a fine of $1000.00, or by both that fine and punishment. (Cal. Penal code 11166(b).)
Elder and Dependent Adult Abuse: Indicators: Bruises, welts, discoloration, swelling Cuts, lacerations, puncture wounds, pale appearance Sunken eyes, hollow cheeks, burns Dehydration, malnourishment, signs of confinement Revised 1-31-2012
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Inappropriate/Inadequate administration of medication Inadequate care Untended bed sores Poor skin hygiene Soiled clothing or bed Reporting Requirements: Mandated Reporters include all health care professionals, care giver, health educators, designated employees of adult protective service agencies and designated employees of local law enforcement agencies. When the abuse is alleged to have occurred in a long-term care facility or to the county adult protective service agency, written report should be sent either to the long term cares ombudsman agency or local law enforcement agency. (use Department of Social services form SOC 341 to report the incident) Where to report: Adult Protective Services – (213) 351-5401 Elder Abuse Hotline – (800) 992-1660 (after business hours) Long Term Care Ombudsman Program – 9800) 334-9473 When abuse has occurred anywhere else, report to the law enforcement agency. Abuse must be reported within 48 hours. What is reported: Physical / Sexual abuse Financial / Mental abuse Neglect Isolation / Abandonment
Domestic Violence/Abuse: All health care professional should report suspected assaultive or abusive conduct by a domestic partner by telephone and follow up with written report to the local law enforcement agency within two (2) working days.
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Accountable Heath Care IPA Provider Policy and Procedures
ACCOUNTABLE HEALTH CARE IPA
ACKNOWLEDGEMENT Accountable Health Care IPA has informed me about the Child Abuse and Neglect Reporting Law as well as Elder abuse and Domestic violence reporting law. I have been explained in detail the requirement of reporting, Immunity and the Penalty for not reporting. I have read the information given to me. I solemnly stat that I have understood the importance of the law. I agree to abide by it.
______________ Name:
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_________________ Signature:
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Accountable Heath Care IPA Provider Policy and Procedures CLAIMS
Claim Submission Instructions Claims for services provided to members assigned to Accountable Healthcare IPA must be sent to the following address: Accountable Healthcare IPA 2525 Cherry Ave #225 Signal Hill, CA 90755-2051 Attn: Claims Department For Disputed Claims, Mail Disputes To: Accountable Healthcare IPA 2525 Cherry Ave #225 Signal Hill, CA 90755-2051 Attn: Claims Appeals/Provider Disputes Department Acknowledgement of Receipt of Claims – To confirm if a claim or claims have been received by Accountable Healthcare IPA, please direct your call to the Accountable Healthcare IPA Customer Service line. Customer Service Representatives are available Monday through Friday from 9:00 a.m. to 6:00 p.m. Please call (562) 435-3333 Calling Accountable Healthcare IPA Regarding Claims – Questions regarding claim filing requirements, provider claim status, or assistance with interpreting EOBs can be directed to the Accountable Healthcare IPA Customer Service line. Customer Service Representatives are available Monday through Friday from 9:00 a.m. to 6:00 p.m. Please call (562) 435-3333 Electronic Claims Submission – For information regarding electronic claims submission, please contact Provider Services by calling (562) 435-3333 or ext. 213 Claims Filing Deadline – Accountable Healthcare IPA deadline for the receipt of a contacted provider claim is ninety (90) calendar days after the date of service, except as required by state and federal law. Any provider contract with deadlines for the receipt of claims that is less than ninety (90) calendar days shall be deemed ninety (90) calendar days. Accountable Healthcare IPA, after review, will allow additional time for “good cause”, providing the provider submits the documentation with the claim to support late filing. If the provider disagrees with Accountable Healthcare IPA determination regarding timeliness of claim submission, the claim can be submitted to Provider Dispute. Reimbursement Time Accountable Healthcare IPA shall reimburse each complete, claim, or portion thereof, whether in state or out of state, as soon as practical but no later than:
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For Health Maintenance Organizations (HMO) Claims: Thirty (30) calendar days for Medi-Cal and forty-five (45) working days after the date of receipt of the complete claim by Accountable Healthcare IPA, unless the complete claim or portion thereof is contested or denied.
Denying, Adjusting, or Contesting a Claim Accountable Healthcare IPA will not improperly deny, adjust, or contest a claim. For each claim that is denied, adjusted, or contested, Accountable Healthcare IPA will provide an accurate and clear written explanation of the specific reason for the action taken within forty-five (45) working days for HMO claims, after the receipt of the claim by Accountable Healthcare IPA. Accurate and clear written reasons for action taken will be included on Accountable Healthcare IPA Explanation of Benefits (EOBs). Claims Tracers and Re-Submissions Claim tracers or re-submissions are utilized by most providers to follow up on claims for which they have received no determination, no payment, or no denial notice. Tracers and re-submissions are not Provider Disputes. Such claims should be stamped “Tracer” or “Re-submission” and should be sent to the current mailing address you are using for your initial claims submissions. Initial Claim Submissions and Determinations Initial claims submissions are first-time submissions of a claim for payment. Initial claim payment and denied determinations are processed claims, and are explained in detail on the explanation of benefits (EOB). You should utilize the EOB to review claim determinations, post the information in your Accounts Receivable, and identify any claim determinations with which you may disagree. It is not the responsibility of Accountable Healthcare IPA to reconcile your Accounts Receivable nor is it acceptable to submit a request for reconciliation as a provider dispute. Provider Claim Dispute Procedures Definition of a Contracted Provider Dispute – A contracted provider dispute is a provider’s written notice to Accountable Healthcare IPA and/or the member’s applicable health plan challenging, appealing, or requesting reconsideration of a claim (or a bundled group of substantially similar multiple claims that are individually numbered) that has been denied, adjusted, or contested or seeking resolution of a billing determination or other contract dispute. Time Period for Submission of Provider Disputes All Provider Disputes must be received by Accountable Healthcare IPA within 365 calendar days from the action (whether by Accountable Healthcare IPA or you) that led to the dispute (or the most recent action if there are multiple actions) that led to the dispute. Provider Disputes that do not include all required information may be returned to you for completion. An amended Provider Dispute, which includes the missing information, may be submitted to Revised 1-31-2012
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Accountable Healthcare IPA within thirty (30) working days of your receipt of a returned Provider Dispute. Time Period for Resolution and Written Determination of Provider Dispute Accountable Healthcare IPA will issue a written determination stating the pertinent facts and explaining the reasons for its determination within forty-five (45) working days after the date of receipt of the Provider Dispute or the amended Provider Dispute.
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Accountable Heath Care IPA Provider Policy and Procedures PROVIDER DISPUTE RESOLUTION REQUEST FORM Instructions:
Please complete the below form. Fields with an asterisk ( * ) are required. Be specific when completing the DESCRIPTIONOF DISPUTE and EXPECTED OUTCOME. Provide additional information to support the description of the dispute. Do not include a copy of a claim that was previously processed. For routine follow-up, please use the Claims Follow-Up Form instead of the Provider Dispute Resolution Form. Mail the completed form to: Accountable Healthcare IPA 2525 Cherry Ave, #225 Signal Hill, CA 90755-2051
*Provider Name:________________________ *Provider TAX ID # / Medicare ID #:____________ Provider Address: ____________________________________________________________________ Provider Type:
MD
Mental Health Professional
Hospital
ASC
SNF
Ambulance
Other___________
Mental Health Institutional DME
Rehab
Home Health
Claim Information:
Single Multiple “LIKE” Claims (complete attached spreadsheet) Number of Claims: ______ Patient Name:______________________________ Date of Birth:______________ * Health Plan ID Number:____________________ Patient Account Number: ___________________ Original Claim ID Number: (If multiple claims, use attached spreadsheet)______________________ Service Date: From: ________To: _________ ( * Required for Claim, Billing, and Reimbursement Of Overpayment Disputes) Original Claim Amount Billed:__________________ Original Claim Amount Paid: _______________ Dispute Type:
Claim
Appeal of Medical Necessity / Utilization Management Decision
Disputing Request For Reimbursement Of Overpayment Seeking Resolution Of A Billing Determination
Contract Dispute Other: __________________
*DESCRIPTION OF DISPUTE: ________________________________________________________________ ____________________________________________________________________________________________ EXPECTED OUTCOME: ______________________________________________________________________ _____________________________________________________________________________________________ Contact Name (please print): _________________________________________ Title: ______________________ Signature: ____________________________________
Date: ________________
Phone Number: ___________________________________ Fax Number: _______________________
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Accountable Heath Care IPA Provider Policy and Procedures
Encounter Data Submission
Accountable Health Care IPA Requirement: All Primary Care Practitioners are required to submit encounter data within 30 days from the date of the service. Why is it important to submit encounter data? Encounter data are used by the health plans in tracking the utilization of services by the members. This allows the health plans to identify pharmacy patterns, prevalence of certain types of diseases and co-morbidities, member’s utilization patterns of medical services, Individual Health Assessment (IHA) within mandated time frame, Healthcare Effectiveness Data and Information Set (HEDIS) study, compliance with the State’s requirements and others. What elements are required in the submission? 1. Patient’s Name 2. Date of Birth 3. Patient’s ID # 4. Date of Service 5. Diagnosis Code 6. CPT Code 7. UCR fees 8. Place of Service (e.g. Office, Hospital, SNF etc) 9. Treating provider Name 10. Treating Provider Address and Phone # 11. Treating Provider License # 12. Individual or Group Tax ID # 13. Facility Name and Address (if different from the billing address) What incentive does primary office get for submitting encounter data? Primary Care Provider will receive $1.00 cents per encounter submitted to AHC IPA on or before 30 days of date of service. What conditions will PCP need to meet to qualify for the incentive? 1. Encounter data must be completely filled out. 2. Encounter data must be submitted within 30 days. Provider will be paid on or before 10th of the month for the previous month activity
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Accountable Heath Care IPA Provider Policy and Procedures What is the method of submission? AHC IPA will accept several format of encounter data information. Some of the examples are HCFA 1500/CMS 1500 form, PM 160 form, Super bills, Computer generated report, Excel spread sheet or any other format approved by AHC IPA. Mail encounters to AHC IPA at 2525 Cherry Avenue, Suite 225. Signal Hill, CA 90755 or fax at 562- 981-7431 How AHC IPA submit Encounter information to Health Plan? On a weekly basis AHC IPA submit all encounter information to some of the health plan (Anthem Blue Cross, Care 1st, Health Net, Molina) directly. Other health plans has a contract with DDD (a clearing house). AHC IPA also submit encounter information to DDD on a weekly basis. DDD submits AHC IPA encounter information to other health plan on a weekly basis (according to contractual agreement) and inform AHC IPA.
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Accountable Heath Care IPA Provider Policy and Procedures
Eligibility Accountable Health Care IPA will provide eligibility roster to Primary Care Provider (PCP) of all its assigned members. Roster will contain the following information: Name Address Phone # Date of Birth Gender Preferred Language Health Plan Name Health Plan ID PCP Name Effective Date: Provider must verify eligibility of member at each visit Provider should verify eligibility thru health plan web site. If PCP have any question about member eligibility please call AHC IPA eligibility department and/or member assigned health plan membership department.
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Accountable Heath Care IPA Provider Policy and Procedures
Member Satisfaction
Purpose: The Quality Management Program upholds a responsibility to the AHC IPA, its members, providers and staff. The responsibilities to the members include the provision of information, assistance, and problem resolution. The responsibilities to the AHC IPA, its providers and staff are to evaluate member concerns and to provide information that will assist in the delivery of high quality services. This responsibility includes the direct actions taken by the staff and providers, their interactions (including liaison) with or referral to AHC IPA departments and providers, and participation in projects that ensure member satisfaction. Scope: Mechanisms to ensure member satisfaction have been implemented to: 1. Respond to each member’s concern in an effective, efficient, and professional manner. 2. Develop a strong working relationship with the AHC IPA staff and management as well as with the providers and their staff. 3. Assist members in selecting or changing a primary care physician and correspond with the contracted health plan regarding this activity. 4. Explain health plan benefits and coverage including coordination of benefits. 5. Provide assistance to members and providers who wish to terminate a relationship with each other. 6. Maintain member confidentiality. 7. Sustain provider respect and reputation. 8. Provide assistance to members who would like to change the site of healthcare delivery. 9. Educate members regarding the AHC IPA managed care system. 10. Provide a cordial response to all member concerns. 11. Identify patterns of member concerns. 12. Evaluate voluntary disenrollments. 13. Contribute to the resolution of problems associated with member concerns. 14. Report problem patterns to the appropriate administrative departments and suggests workable resolutions. 15. Participate in problem resolution projects.
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Accountable Heath Care IPA Provider Policy and Procedures Goals: The goals of maintaining member satisfaction include: 1. Conduct member satisfaction surveys once a year to gather information for the quality improvement process. The survey will be performed on a minimum of 20 % of the total membership with a goal of 40 % response rate. 2.
Complete all initial procedures related to member concerns within AHC IPA, health plan and regulatory approved time frame (within one working day upon receipt).
3.
Provide an initial response to each member concern within an AHC IPA approved time frame (within one week upon receipt).
4.
Provide accurate documented analysis of the member concern to administrative staff of the appropriate AHC IPA departments and contracted health plans.
5.
Contribute to the maintenance of member brochures and member relations materials designed to meet the needs of the various AHC IPA populations.
6.
Identify and collect appropriate data, which supports member concerns (e.g., lack of information to insurance carriers, double billing or wrongfully applied payments.)
7.
Implement an effective process to enhance the quality of member relations and reduce organizational concerns in order to emphasize effective operations within the AHC IPA.
8.
Assess and enhance member satisfaction with AHC IPA services.
9.
Evaluate member complaints, requests to change providers or facilities, and member disenrollments at least on an annual basis.
Policy: 1. All AHC IPA members or their legal guardians will be aware of the member rights and responsibilities and the process to express concerns/grievances regarding care and payment for care. 2.
A list of the member’s rights and responsibilities will be posted in the provider offices. Member Rights & Responsibilities are included in the Welcome Letter sent to new members.
3.
An explanation of the process for expressing concerns/grievances will be included in the new member welcome letter and the member handbook.
4.
Member concerns will be directed to the appropriate AHC IPA staff member.
5.
Quality Management issues will be directed to the Utilization Management Nurse and the Quality Management Committee.
6.
The Quality Management Committee will handle risk Management issues.
a.
The issues initially will be directed to the Utilization Management Nurse to be processed according to AHC IPA Quality Management policy and procedure.
7.
An issue of concern or grievance will be expressed by the member (patient) or legal guardian via telephone, in writing or in person. a.
The information will be handled according to AHC IPA approved confidentiality policies and procedures.
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8.
Accountable Heath Care IPA Provider Policy and Procedures The appropriate staff member will identify the core issue of the concern/grievance and determine if it is a claim-processing problem, a member concern or a complaint.
9.
The Utilization Management Nurse will gather necessary data.
10.
The medical record of the member (patient) and other supportive information will be obtained according to AHC IPA approved policy and procedure.
11.
The impact of the situation will be assessed, and the Utilization Management Nurse will define the resource criteria whether it is medical staff, nursing, quality of care, billing or other (e.g., hospital system).
12.
The Quality Management staff will send a letter to the providers and/or staff involved, requesting a documented response to the situation.
13.
The documented events and provider/staff response will be taken to the Quality Management Committee for analysis, problem resolution and recommended follow-up action.
14.
The Utilization Management Nurse will carryout the follow-up actions, which include sending a letter to the member, the provider and the health plan.
15.
The Quality Management Nurse will monitor the outcome of the actions.
16.
The documented member concern and follow-up process will be kept in a confidential file.
17.
A log and statistics of the processed member concerns will be maintained by the Quality Management Nurse and will be reported to the Quality Management Committee and contracted health plans at least on a monthly basis. Grievances will be processed according to the AHC IPA approved policy and procedure (see Member Complaint, Grievance and Appeal Process).
18.
The Quality Management staff will assist with the periodic assessment and enhancement of member satisfaction with the AHC IPA services. The assessment will include review of: a. Member complaints/grievances b. Member requests to change providers or facilities c. Member disenrollment
19.
Quality Management staff will assist with the process of conducting member satisfaction surveys, which will be done on a frequent basis according to AHC IPA and contractual requirements. Population-specific studies also will be conducted. Other AHC IPA departments will be involved in the survey process as appropriate. The members will evaluate AHC IPA services and especially the provision of health care services. a.
Appropriate methods will be used to collect data for the assessment activities 1. The appropriate population will be identified 2. Appropriate samples will be drawn from the affected population 3. Valid and reliable data will be collected
b.
Data will be collected and analyzed for the assessment activities. Sources of dissatisfaction will be identified and addressed by the AHC IPA staff.
c.
Opportunities for improvement will be identified and decisions will be made as to which opportunities to pursue.
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d.
e.
20.
Accountable Heath Care IPA Provider Policy and Procedures The AHC IPA providers and staff will be informed of the results of member satisfaction survey activities and told if corrective action is necessary. 1. Provider-specific information will be shared directly with the particular provider or facility. 2. Overall findings and actions will be reported to the general population of AHC IPA providers and facilities. 3. The AHC IPA providers and facility staff feedback on the survey results will be included in the final report summary. 4. If corrective action will be implemented, the providers and facility staff will be notified of the follow-up evaluation results. Interventions will be implemented to improve performance. 5. The effectiveness of the interventions will be measured. The survey results, the implementation of corrective action (as appropriate), and an evaluation of the follow-up action will be presented to the Quality Management Committee and the contracted health plans according to contractual agreement.
Information on member satisfaction and complaints will be used in the re-credentialing process of AHC IPA providers.
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Accountable Heath Care IPA Provider Policy and Procedures Member Satisfaction Survey 1
How long did you wait to get an appointment To see your primary care doctor within 1 wk To see a Specialist
1-2 wks
3 weeks 4 or more wks
within 1 wk 1-2 wks
3 weeks 4 or more wks
2.
How long did you wait to see your physician once you have arrived at his/her office (past your appointment time?) 0-30 Min 30-60 min More than an hour
3.
Was the front office staff courteous to you?
Yes
No
4
Was the back office staff courteous to you?
Yes
No
5.
Was your physician courteous to you?
Yes
No
6
What is your overall satisfaction with the care and service provided through your physician and his/her medical group? Very satisfied Satisfied Dissatisfied
7.
Would you recommend your physician to family and friends? Yes
8
How long did you wait to get an answer on your referrals from AHC IPA? 1-3 Days
9
4-5 days More than 5 days Dissatisfied Dissatisfied
11
Did your provider help you regarding your treatment?
12
How long did you wait to resolve your grievance? within 1 wk
Not applicable
1-2 wks
3 weeks 4 or more wks
Not applicable
No
No
Did your provider give you Cultural & Linguistic information/referral for your health related concern? Yes
17
3 weeks 4 or more wks
No
Did your provider give you health education materials/referral for your health related concern? Yes
16
Yes
Did your provider explain to you about your rights and responsibilities as a member of AHC IPA? Yes
15
1-2 wks
Not applicable
How long did you wait to get your claims paid? within 1 wk
14
Not applicable
How satisfied were you with the case management program (services) provided: Very satisfied Satisfied
13
Not applicable
How satisfied were you with the services provided by your specialist: Very satisfied Satisfied
10
No
No
Did your provider give you free interpreter information/referral for your health related concern? Yes
Additional comments:
No
______________________________________________________________
Your primary care physician's name: ___________________________________ Please return survey to:
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ACCOUNTABLE HEALTH CARE IPA 2525 Cherry Avenue, Suite 225 Signal Hill, CA 90755 Tel: (562) 435-3333 // Fax: (562) 216-5434
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Accountable Heath Care IPA Provider Policy and Procedures
Provider Satisfaction
Purpose: The Quality Management Program upholds a responsibility to the AHC IPA, its members, providers and staff. The responsibilities to the providers include the provision of information, assistance, and problem resolution. The responsibilities to the AHC IPA and staff are to evaluate provider concerns and to provide information that will assist in the delivery of high quality services. This responsibility includes the direct actions taken by the staff, their interactions (including liaison) with or referral to AHC IPA departments, and participation in projects that ensure provider satisfaction. Scope: Mechanisms to ensure provider satisfaction have been implemented to: 1. Respond to each provider’s concern in an effective, efficient, and professional manner. 2. Develop a strong working relationship with the AHC IPA staff. 3. Explain health plan benefits and coverage including coordination of benefits. 4. Educate providers regarding the AHC IPA managed care system. 5. Provide a cordial response to all provider concerns. 6. Identify patterns of provider concerns. 7. Contribute to the resolution of problems associated with provider concerns. 8. Report problem patterns to the appropriate administrative departments and suggests workable resolutions. 9. Participate in problem resolution projects. Goals: The goals of maintaining provider satisfaction include: 1. Conduct provider satisfaction surveys once a year to gather information for the quality improvement process. 2. Complete all initial procedures related to provider concerns within AHC IPA, health plan and regulatory approved time frame. 3. Provide an initial response to each provider concern within an AHC IPA approved time frame. 4. Provide accurate documented analysis of the provider concern to administrative staff of the appropriate AHC IPA departments and contracted health plans. 5. Contribute to the maintenance of the Provider Manual. 6. Identify and collect appropriate data, which supports provider concerns. Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures 7. Implement an effective process to enhance the quality of provider relations and reduce organizational concerns in order to emphasize effective operations within the AHC IPA. 8. Assess and enhance provider satisfaction with AHC IPA services such as referral process, discharge planning, complaints, committee meetings, and/or UM criteria. 9. Actively obtain information on how to improve provider satisfaction, at least annually Policy: 1. Quality Management staff will assist with the process of conducting Provider satisfaction surveys, which will be done every year. 2. All AHC IPA Providers will be made aware of the process to express concerns/grievances. 3. An explanation of the process for expressing concerns/grievances will be included in the Provider Manual. 4. The Quality Management Committee will handle risk Management issues. 5. The Provider via telephone, in writing or in person, can express an issue of concern or grievance. 6. Quality Management issues will be directed to the Quality Management Nurse and the Quality Management Committee. 7. At least 20 % of the AHC IPA providers will be served 8. Appropriate methods will be used to collect data for the assessment activities 9. The appropriate population will be identified 10. Appropriate samples will be drawn from the affected population 11. Valid and reliable data will be collected 12. Member, provider and follow-up process will be kept in a confidential file. 13. The AHC IPA providers and staff will be informed of the results of Provider satisfaction survey activities and told if corrective action is necessary. 14. Overall findings and actions will be reported to the general population of AHC IPA providers and facilities. Procedure: 1. The Quality Management staff will respond via letter or telephone acknowledging the receipt of the complaint/grievance. 2. The issues initially will be directed to the Quality Management Nurse to be processed according to AHC IPA Quality Management policy and procedure. 3. The information will be handled according to AHC IPA approved confidentiality policies and procedures. 4. The appropriate staff member will identify the core issue of the concern/grievance and determine if it is a claim-processing problem, a Provider concern or a complaint. 5. The QM Nurse will gather necessary information related to the grievance. 6. The QM Nurse will carryout the follow-up actions, which include sending a letter to the provider and the health, plan. Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures 7. The QM Nurse will monitor the outcome of the actions. 8. The impact of the situation will be assessed, and the QM Nurse will identify the grievance type whether it is medical staff, nursing, quality of care, billing or other (e.g., hospital system). 9. A log and statistics of the processed provider concerns will be maintained by the QM Nurse and will be reported to the Quality Management Committee and contracted health plans at least on a monthly basis. Grievances will be processed according to the AHC IPA approved policy and procedure (see Complaint, Grievance and Appeal Process). 10. The documented events and response will be taken to the Quality Management Committee for analysis, problem resolution and recommended follow-up action. 11. The Quality Management staff will assist with the periodic assessment and enhancement of provider satisfaction with the AHC IPA services. The assessment will include review of provider complaints/grievances 12. Data will be collected and analyzed for the assessment activities. Sources of dissatisfaction will be identified and addressed by the AHC IPA staff. 13. Opportunities for improvement will be identified and decisions will be made as to which opportunities to pursue. 14. The AHC IPA providers and facility staff feedback on the survey results will be included in the quarterly report summary. 15. If corrective action will be implemented, the providers and staff will be notified of the follow-up evaluation results. Interventions will be implemented to eliminate deficiencies and improve performance.
16. Once corrective measure has been instituted, the effectiveness of the interventions will be analyzed. 17. The survey results, the implementation of corrective action (as appropriate), and an evaluation of the follow-up action will be presented to the Quality Management Committee and the contracted health plans according to contractual agreement.
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Accountable Heath Care IPA Provider Policy and Procedures Provider Satisfaction Survey Your input is very important to us! Please complete the following survey along with your comments and return it to AHC IPA. Please check the appropriate response. Strongly Agree
Agree
Neutral
Disagree
AHC IPA staff returns calls promptly The AHC IPA staff is courteous and helpful. Your questions are answered to your satisfaction AHC IPA referral / authorization forms are easy to use. Referral/authorizations are returned to you in a timely fashion. UM information are updated and informed to you in a timely manner AHC IPA ensure adequate coordination of care among provider for your member Coordination of Care provided in a timely manner Members are satisfied with the AHC IPA UM process Specialist network is sufficient enough to address your need Questions on claims are handled quickly and appropriately. Claims are processed in a timely fashion. Capitation checks sent in a timely manner C & L issues related to member and their ability to access services are addressed Health Education services provided by AHC IPA and Health Plans are satisfactory.
COMMENTS:______________________________________________________________ __________________________________________________________________________ PLEASE RETURN SURVEY TO:
Accountable Health Care IPA 2525 Cherry Ave, Suite 225 Signal Hill, CA 90755
Fax (562) 216-5434
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Strongly Disagree
Accountable Heath Care IPA Provider Policy and Procedures
Utilization Management Program Purpose The purpose of this plan is the provision of high quality health care and appropriateness of patient care, pursing opportunities to improve on patient care and resolving problems identified by various modalities. AHC IPA through its Utilization Management program, will also monitor and ensure the availability and accessibility of the care being provided, appropriateness and timeliness of the services it provides. The Board of Directors has adopted and implemented this UM Program to fulfill AHC IPA’s responsibility to its patients, health plan enrollees, and the community services. Goal The goal of AHC IPA’s Utilization Management Program are to: Objectives 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Continuously maximize and improve the health care services delivered to AHC IPA’s members. Provide access to health care services in a timely cost effective manner Identify quality of care issues and inform Quality Management department. Case manage high risk members and ensures that appropriate quality of care is delivered Evaluated and update UM program if necessary at least annually
Provide access to the most appropriate and cost efficient healthcare services. Ensure authorized services are covered under the member’s health plan benefits. Develop systems to evaluate and determine which services are consistent with accepted standards of medical practice. Perform peer review in conjunction with the Quality Management Program when it is necessary. Coordinate thorough and timely investigations and responses to member and provider grievances, which are associated with utilization issues. Initiate necessary procedural revisions to prevent problematic utilization issues from reoccurring. Ensure that services, which are delivered, are medically necessary and are consistent with the patient’s diagnosis and level of care required. Facilitate communication and develop positive relationships between members, physicians and health plans by providing education related to appropriate utilization. Evaluate and monitor healthcare services provided by AHC IPA contracted providers by tracking and trending data. Monitor, evaluate and improve continuity and coordination of care. Identify over utilization and under utilization of services. Monitor referrals, denials and appeals for appropriateness of medical services.
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Accountable Heath Care IPA Provider Policy and Procedures 13. 14. 15. 16. 17. 18. 19. 20.
Identify “high risk” members and ensure that appropriate care is delivered by accessing the most efficient resources. Reduce overall healthcare expenditures by developing and implementing effective health promotion programs. Use utilization management data in the process of re-credentialing providers. Continuously monitor, evaluate and improve the Utilization Management Program, and integrate the UM Program appropriately into the Quality Management Program. Ensure cohesive AHC IPA interdepartmental processes with the Utilization Management process. Identify potential quality of care/quality of service issues. Monitor the clinical decision making process, identify and refer questionable cases to the Quality Management/Peer Review Committee for evaluation. Monitor behavioral health care aspect of the program
Committee Structure: The Utilization Management Committee oversees the implementation of comprehensive, systematic, continuous processes, which make the Utilization Management Program effective. The UM Committee meets its program objectives in part by conducting prospective, concurrent, and retrospective review of services for inpatient hospitalizations, emergency care, outpatient surgery, rehabilitation, home and hospice care using health plan care guidelines as necessarily for ambulatory care, inpatient surgical care and home care. Selected services from outpatient, ancillary, and physician offices also are reviewed. The UM Committee monitors quality, continuity, and coordination of care as well as over-utilization and under-utilization of services. Any perceived or actual utilization management problems are handled by the UM Committee. The Quality and Utilization Management Committees work together on overlapping issues. The UM Committee actively manages utilization of services by making the most appropriate use of available healthcare resources. Sound utilization plans are defined, developed and executed by the Utilization Management Committee. The utilization plans meet budget constraints and reflect support and consistency involved with aggregate services. The UM Committee oversees and monitors all delegated utilization management activities. The entire period of care from the first treatment encounter to the member’s return to a healthy state is effectively managed by the AHC IPA providers, staff, and ultimately the UM Committee. The UM Committee recognizes and applies appropriate medical benefits to the management of cases. Treatment guidelines which lead to the best health status outcomes are reviewed, revised, approved and utilized by the UM Committee. The UM Committee actively develops, implements and evaluates the most effective and efficient treatment pathways which return members to optimal states of health. High risk/high cost cases are managed closely by the UM Committee to ensure that the most cost-effective services are identified, coordinated, implemented, and evaluated on a continual basis. This long-term process involves the UM Committee’s use of appropriate clinical, individual and environmental resources.
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Accountable Heath Care IPA Provider Policy and Procedures AHC IPA does not penalize or provide incentives to providers involved in the utilization review process to make inappropriate review decisions. The UM Committee establishes and maintains solid avenues of communication and networking between providers, staff, facility and health plan staff and members. New and existing technology will be evaluated by the UM Committee. Additionally, the UM Committee may review pharmaceutical services statistics which are illustrated in cost and utilization analysis reports (usually, reports are provided by the contracted health plans). Functions/Responsibilities The UM Committee oversees the timely development and implementation of an effective utilization management program which includes the following: 1. Continuous improvement of the UM program which oversees the delivery of high quality care to members in the most cost-effective manner. 2. Determination of authorization for services based on relevant clinical information and physician consultation, which reflect effective and efficient utilization practices. Implementation of approved written utilization review decision criteria, which are based on reasonable medical evidence to make utilization decisions. 3. Annual evaluation revision (as appropriate) of all aspects of the Utilization Management Program including the utilization management plan, policies and procedures, annual report summary, and utilization guidelines. The written UM program description outlines structure and accountability. a. Development and implementation of utilization management policies and procedures. b. Development and implementation of an annual utilization management plan. c. Review and revision of AHC IPA approved prospective, concurrent and retrospective review criteria and guidelines to ensure their consistency with standard medical practices. Application of the AHC IPA approved criteria and guidelines for authorization determination while acknowledging differences for each case. d. Evaluation of measurement tools and the evaluation process, which ensures that criteria and guidelines are applied similarly among the health care professional reviewers when making utilization, review decisions. Conduct assessments of clinical information used to support UM decisions. e. Obtain contracted provider feedback regarding the effectiveness of the UM Program. f. Monitor and evaluate to ensure that appropriately licensed health professionals supervise all review decisions, and that a licensed physician only can deny/modify/defer UM decision that are based on medical appropriateness. g. UM Program annually reviewed, revised as necessary and approved by UM Committee / Quality Management Committee. Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures 4
Oversight of utilization management standard compliance, problem cases, and compliance of providers with AHC IPA standards and procedures. Use of boardcertified physicians from appropriate specialties to assist in making medical appropriateness decisions.
5
Identification and investigation of specific and general utilization management problems especially in relation to trending patterns by providers, over-utilization and under-utilization, resource use, access, and performance.
6
Monitoring of the resolution of utilization problems and overseeing the process of assessment, conclusions, recommendations, actions and follow-up evaluation. Quality of care issues will be referred to the QM Committee. Involvement in peer review activities in conjunction with Quality Management.
7 8
Facilitation of effective utilization management networking between the AHC IPA and the contracted hospitals and health plans.
9
Conduction of retrospective review and payment determination of claims, which have not been adjudicated. Serve as a review group to assist in the interpretation of medical benefit processes and use relevant information sources to make determinations of benefit coverage and medical appropriateness. Contribute to comprehensive education programs for the AHC IPA providers, staff and members. Ensure that approved updated criteria and guidelines are communicated to contract providers and are available upon request. Approval and documentation in the minutes of any actions or decisions made by he UM Committee. Assurance that minutes accurately reflect the activities of the UM Committee meetings. Development of subcommittees and specialty task forces to assist the UM Committee by:
10
11
12
13 i. ii. iii. iv. v. vi. vii.
viii.
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Contributing to the development of primary care physician education sessions regarding specialty care. Assisting in obtaining member and provider feedback regarding the UM process and utilization management issues. Analyzing provider utilization, developing or revising utilization guidelines, and delineating the various provider roles. Monitoring and evaluation of referrals to non-contracted providers and facilities. Recommending new specialists to the Membership/Credentialing Committee. Developing criteria for outcome and focus studies. Developing clinical pathways to be used as a reference tool by the AHC IPA providers. Assisting in the process for evaluating the inclusion of new medical technologies and the new application of existing technologies in the benefit package.
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Accountable Heath Care IPA Provider Policy and Procedures ix.
Evaluating and updating criteria for determination of medical appropriateness at specified intervals. x. Developing and implementing standards for timeliness of UM decisionmaking based on clinical urgency. Overseeing the evaluation and implementation of actions to improve performance (as appropriate) for consistently meeting these standards. xi. Evaluating appropriateness of medical appropriateness denials and the clarity of the documentation and communication of the reasons for the denial. xii. Overseeing delegated UM Program activities. xiii. Monitoring and evaluation of the UM Program with implementation of quality improvement activities. xiv. Sub committee will report to UM committee at least on a quarterly basis. 14 The UM committee members will not participate in decision-making involving review of their own cases and that every member will sign a Conflict of Interest statement 15 The content of the UM Committee meetings will be kept confidential and all members will sign a confidentiality, conflict of interest and financial incentive statement. 16 The UM Committee will report to the QM Committee/Governing body at least on a quarterly basis. Behavioral Health Care: Behavioral health care is a carved out services for some of the health plans for Medi-Cal members but it is a covered benefits for Medicare members. PCP may be involved and responsible in some aspect of behavioral health care of the members. He/she is a liaison between member, AHC IPA, behavioral health care providers and the HMO. AHC IPA will continue to credential behavioral health care providers. One of the provider will be a part of the UM committee. Primary care providers are responsible for referring the member to AHC IPA. AHC IPA will review treatment authorization request and involve behavioral health care provider for decision as deemed necessary. Behavioral health care practitioner will be actively involved in the implementation of the behavioral health care aspect of the UM program. (He/she will be involved in setting policy, reviewing cases and participating in the committee meetings if necessary) Referring a member to a behavioral health care provider for in-patient and/or out-patient care, AHC IPA will utilize member’s assigned HMO facility. HMO is responsible to credential behavioral health care facility. Authorization / Referral: The Utilization Management Committee oversees the development and implementation of an effective referral/authorization process. This process and structure involves the UM Program’s methods for reviewing and authorizing (or denying) requested healthcare services. Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures Responsibilities will be assigned to the appropriate health care professionals. The process is evaluated, updated and approved annually by senior management or the Quality Management Committee. Following DMHC, DHS, CMS and Health Plan guidelines, AHC IPA has adopted the following timeframes in the referral/authorization process: 1.
Expedited Pre-Service referrals and authorization requests will be processed right away, and will take no longer than 72 hours for a response to be given to the provider. The UM nurse will contact the Medical Director or physician designee for a determination.
2.
Routine (Non-urgent) Pre-Service referral and authorization requests will be processed within Five working days. (If all information is available.) The processing time frame also will include complex cases, which require UM Committee review and/or further research and management.
4.
Prospective Review: Pre authorization
5.
Concurrent Review
6.
Retrospective Review: Post authorization
Levels of Review 1. 2. 3.
Prospective review. Review of requests for service authorization in order to monitor continuity and coordination of care and to assist in the utilization of appropriate services. Concurrent review. Concurrent review is an assessment determining medical necessity or appropriateness of services as they are being rendered. Retrospective review. Assessment of the appropriateness of medical services on a caseby- case or aggregated basis after the services have been provided
Confidentiality: AHC IPA treats with confidentiality all materials being reviewed by the UM Committee. All UM Committee members shall be required to sign a confidentiality agreement annually. The confidentiality agreement shall be maintained in the provider file or employee files as appropriate. Health Plan Representative may attend as an observer and should sign the required Confidentiality Statement. (Refer to Quality Management "Risk Management Program" Policy/Procedure and sample form "Provider Panel Member Confidentiality Statement.”) Conflict of Interest The review process is multi-tiered, involving both physicians and non-physicians, and may be multi-disciplinary. It is possible that screening or review of patient care will require the participation of those professionally involved in that case. If at any time a potential for conflict of interest is identified, only those not having direct involvement in the provision of care will conduct further review. Outside physician reviewers may be utilized when it is necessary to Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures
eliminate a possible conflict of interest and reach an objective conclusion. All UM Committee members and UR participants shall be required to sign a Conflict of Interest Form annually. AHC IPA does not penalize or provide incentive to committee members or attendees involved in the utilization review process to make inappropriate review decision. AHC IPA encourage provider to make decision or give opinion on medical necessity and appropriateness of care and services AHC IPA recognize the risk of underutilization Providers are informed of AHC IPA “Confidentiality, Conflict of interest and Financial Incentive” statement signed by committee members and UM staff members every year by mail.
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Accountable Heath Care IPA Provider Policy and Procedures Confidentiality & Conflict of interest agreement
Policy: All Quality Management and Utilization Management review shall be free of conflict of interest. Individuals or groups with a conflict of interest will not perform QM or UM reviews. A reviewer or committee member will be considered to have a conflict of interest if he/she has any involvement in the care of the member involved in the review or if he/she has any other involvement in the case, which impairs his/her objectivity in performing the review. All Quality Management and Utilization Management review is strictly confidential, including copies of minutes, reports or studies. AHC IPA will maintain documents of QM and UM activities and reports in a manner, which ensures confidentiality. Procedure: 1. AHC IPA staff members involved in QM & UM, QM and UM committee members and all peer reviewers will sign a Confidentiality, Conflict of Interest and Financial Incentive Agreement 2. All QM and UM documents will be restricted solely to authorized staff, members of QM committees, peer reviewers and reporting bodies as specifically authorized by the QM committee. 3. Committee members and peer reviewers with a conflict of interest in a particular case will notify the person requesting peer review or the Medical Director and will excuse him/herself from any committee meeting, from receiving related materials and/or from completing the review. 4. Storage and disposal of confidential QM documents will be done in a manner, which will protect confidentiality of the documents or data. Physical forms or hard copies, which include originals and photocopies, are kept and maintained in a locked storage units and areas. Such documents will be shredded upon disposal. Electronic data and files are kept in electronic storage drives in a secured environment where access is limited to the minimum necessary, controlled and tracked. 5. Confidential documents may include, but not limited to: committee minutes and agendas, peer review reports and findings, PQC records, grievance records, and any correspondence or memos relating to confidential issues where the name of a provider or member is included. 6. All communications to members regarding grievances should be addressed to the member, not the member's parent or guardian. However, when the grievance does not involve a sensitive issue as defined by the Privacy Act (45 CFR 164.530), and the grievance was filed by a parent on behalf of a minor child or by a guardian of a physically or mentally incompetent member, correspondence can be addressed to the parent or guardian. 7. The Privacy Act (45 CFR 164.530) precludes disclosure of sensitive information. Information must not be provided to a parent or guardian of a minor child when the services involve the following diagnostic codes; alcoholism, abortion, drug abuse, venereal disease. PCPs are encouraged to do appropriate counseling. 8. Members are granted access to their medical data, information and records from their providers at any time. They can also grant permission or authorization for the release of their information and Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures records for purpose of treatment, payment or health care operation in a confidential manner. The member must first sign an authorization form to grant permission. 9. Should a situation arise in which within the above polices and procedures are not followed, the QM Committee and the Medical Director will immediately determine appropriate action and notify the individual involved in writing to correct either the breach of confidentiality or conflict of interest. 10. AHC IPA practitioners, providers, members and employee will be informed of “Confidentiality, Conflict of Interest and Financial Incentive” statement signed by all UM committee members and UM staff members. 11. AHC IPA and network provider will not dispose of any medical information negligently, nor intentionally share, sell or use of medical information for any purpose not necessary to provide health care services to the member, except as otherwise authorized. 12. AHC IPA members are not required to sign consent to disclose any medical information as a condition to be treated by AHC IPA providers. 13. If patient has undergone psychotherapy treatment in an out patient setting, Confidentiality of Medical Information Act states that the requesting provider must submit a written request to the provider of services, which information is required and signed the request. Copy of the request should be given to the member and confidentiality should be maintained 14. AHC IPA will never publicly post or display an individual’s Social Security Number in any manner 15. Member or the practitioner will not transmit SSN over the Internet unless the connection is secured or the SSN is encrypted. 16. SSN is not required to access AHC IPA Internet web site. User ID and Password will be provided. 17. Member’s SSN will not be printed on any materials that are mailed to the member unless state or federal law requires the inclusion of the SSN on the document to be mailed. 18. AHC IPA will distribute affirmative statement to all practitioners and staff members every years
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Accountable Heath Care IPA Provider Policy and Procedures CONFIDENTIALITY, CONFLICT OF INTEREST AND FINANCIAL INCENTIVE STATEMENT As a member of the AHC IPA’s Utilization Management Committee charged with the duties of evaluation and improvement of quality of care rendered of said IPA, I recognize that confidentiality is vital to the free, candid and objective discussion necessary for effective management. Therefore, I agree to respect and maintain the confidentiality of all discussions, deliberations, records, and other information generated in connection with all committee and other activities and I understand that by signing this agreement, I am binding myself by contract to maintain such confidentiality. I agree that I will not make any voluntary disclosures of such confidential information except to persons authorized to receive such information. Furthermore, in participating on the committee, I am relying on every other member of the Provider panel and every other individual involved in IPA affairs to similarly preserve the confidentiality of the activities. I understand that other provider panel members and individuals involved in IPA affairs have entered, or will enter into agreements identical to this one and I am a beneficiary of such agreements. I enter into this agreement for the express benefits of the other members of the provider panel and other individuals involved in IPA affairs and for the express benefit of the IPA. Furthermore I state that I have no financial gain or any material gain what so ever as a member of the participating committee. If any member or provider is related to me, employed by me, assigned to me or treated by me or by my organization, I will not participate in any discussion, give opinion or cast vote. I understand that I will not participate in any quality of care issues related to my practice or me. AHC IPA does not specifically reward or penalize practitioners or other individuals for issuing denials of coverage or service care. AHC IPA encourage provider to make decision based only on medical necessity, appropriateness of care and services and existence of coverage. AHC IPA assured practitioners the independence and impartiality in making referral decisions that will not influence hiring, compensation, termination, promotion or any other similar matter Financial incentives for UM decision makers do not encourage decisions that results in underutilization. AHC IPA recognize the risk of underutilization This agreement and obligation of strict confidentiality shall survive the termination of my provider panel membership. Name: ____________________________________ Signature:
Date:
Witness:
Date:
Accepted:
Date: Medical Director
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Accountable Heath Care IPA Provider Policy and Procedures
ACCOUNTABLE HEALTH PLAN MEDICAL GROUP
PLEASE ADDRESS ALL CORRESPONDENCE TO: 2525 Cherry Ave., Suite 225 Signal Hill, California 90755
1045 Atlantic Avenue, Suite 818 Long Beach, California 90813 (562) 436-8117
Telephone (562) 435-3293 Fax (562) 595-0673
1760 Termino Avenue, Suite 116 Long Beach, California 90804 (562) 597-8885
Health Plan Representative Confidentiality Statement
I, _______________________________ hereby represent and warrant that I am an authorized representative of _____________________ ("Plan"). I acknowledge and agree that I have been granted permission by AHC IPA to review/audit certain confidential records as part the process and is subject to the following terms and conditions 1.
I agree to respect and maintain the confidentiality of all discussions, records and information generated in connection with the Meeting and agree not to disclose such information except to authorized representatives of Plan for use in peer review activities of Plan or as is otherwise required by state or federal laws or regulations.
2.
I further acknowledge and agree that I shall not testify or provide any written statements or information of any kind or nature relating to the Meeting in any discovery process (including but not limited to depositions and interrogatories) or any administrative or court hearing or proceeding unless compelled to do so by a court of competent jurisdiction.
3.
I further agree to raise all legal defenses, privileges and immunities that may be available at law or in equity to preserve the confidentiality of and to prevent the disclosure of all records and information generated in connection with the Meeting.
______________________________ Signature
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Accountable Heath Care IPA Provider Policy and Procedures
Referral / Authorization process Purpose: The Utilization Management Committee oversees the development and implementation of an effective referral/authorization process. This process and structure involves the UM Program’s methods for reviewing and authorizing (or denying) requested healthcare services. Responsibilities will be assigned to the appropriate health care professionals. The process is evaluated, updated and approved annually by senior management or the Quality Management Committee. Scope: The UM staff work within their scope of practice and in conjunction with the Medical Director or physician designee and the UM Committee to assign authorizations appropriately. A designated senior physician will have substantial involvement in the referral/authorization process. Appropriately licensed health professionals will supervise all review decisions. All requests for authorization of services will be processed according to AHC IPA approved policies and procedures. Policy: The UM staff will follow the AHC IPA’s approved process for reviewing and authorizing (or denying) requested services. The authorization/denial determinations will be based on medical necessity and will reflect appropriate application of the AHC IPA’s approved practice guidelines and type of coverage (limitation and exclusion). Information will be clearly documented and appropriately available for review. AHC IPA medical director or physician designee will consult with the treating practitioner whenever necessary to discuss or request relevant clinical information before making UM decision. Medical director is available by phone for providers to discuss authorization of health care services. To make appropriate UM decision, AHC IPA will consider characteristics of the local delivery system, such as availability or benefit coverage of SNF, Sub Acute, home healthcare within service area and ability of local hospitals to provide needed services LVN is the minimal level of training and licensure to supervise UM activities.
Procedure: The AHC IPA UM Committee will determine how closely managed the referral process will be in regard to authorization of particular services. For example, whether all referrals from the PCP to a specialist require authorization, or if only follow-up specialist visits and certain specialist referrals need to be authorized or if only follow-up visits require authorization. Similarly, if the UM Committee determines that certain services will be automatically authorized, a list of those services and criteria will be made available to the UM staff and providers.
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Accountable Heath Care IPA Provider Policy and Procedures The following is an example of the referral/authorization process: 1.
Practitioner/Provider send TAR (treatment requests for authorization) to the AHC IPA UM Department by mail or fax.
2.
The AHC IPA staff date stamped the request when it is received.
3.
Member eligibility and benefits are checked.
4.
Emergent/urgent requests are processed immediately. If provider has not stated the type of request (e.g. Routine, Urgent, Emergent), TAR will be evaluated immediately to determine status of the TAR. (date and time stamped for urgent/emergent request)
5.
The request is checked for complete information such as: a. Member Name b. Member’s Health Plan c. Other Insurance d. Member ID # e. Requesting Practitioner/Provider f. Referral Practitioner/Provider g. Services which are required as a result of an accident (are specified as such and the location of the accident is noted: work, home, auto, other) h. Diagnosis (ICD-9 Code) i. Clinical History/Findings which justify the requested procedure j. Attempted treatment, other consults k. Medications l. Requested care, procedure, or test (CPT 4 code) m. Location or facility n. Description of service (inpatient, outpatient, office) o. Estimated length of stay (for inpatient requests)
6.
If information is incomplete, the request is held and the necessary data is obtained from the treating/requesting physician.
7.
The member’s file information then is accessed if it is available.
8.
Un-coded services are coded appropriately.
9.
The request is submitted to the licensed personnel who will be responsible for completing the authorization process.
10.
The licensed health professionals check the information and coding for accuracy and necessary corrections are made. Approved practice guidelines and criteria are applied and qualified health professionals make an authorization determination.
11.
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12.
Accountable Heath Care IPA Provider Policy and Procedures Complex cases are referred to the Medical Director/Utilization Management Committee. Boardcertified physicians from appropriate specialty areas also assist in making determinations of medical appropriateness. Behavioral health care practitioners are available to review cases pertaining to their specialty. (List of board certified specialist available)
13.
Case management and concurrent review cases are submitted to the appropriate staff for followup.
14.
Only California licensed physicians who are competent to evaluate specific clinical issues may deny or modify requests for services based on medical appropriateness.
15.
All authorization requests are followed by notification to the providers of the determination.
16.
Approved requests will include an authorization number for the specific services authorized.
17.
Denials for requested services will include a clearly documented letter to the provider and the member explaining the reason for the denial, suggesting an alternative treatment plan, and informing them of the AHC IPA and the member’s health plan appeals process.
Time Frames The AHC IPA will meet all regulatory and contracted health plan standards for the amount of time allowed to process referral/authorization requests. The AHP will make utilization decisions in a timely manner and accommodate the urgency of individual situations. AHC IPA establishes standards for timeliness of UM decision-making. Examples are: 1. Expedited Pre-Service referrals and authorization requests will be processed right away, and will take no longer than 72 hours for a response to be given to the provider. The UM nurse will contact the Medical Director or physician designee for a determination. 2. Routine (Non-urgent) Pre-Service referral and authorization requests will be processed within five working days for Medi-Cal and Commercial members and 14 days for Medicare members. (if all information is available). The processing time frame also will include complex cases, which require UM Committee review and/or further research and management. Refer to ICE template for timeliness 3. Injectables: Decision for injectables TAR will be made within 24 hrs or One (1) business day. Practitioner and the pharmacy will be informed via written / electronically within 48 hrs or Two (2) business days. Some of the injectables are authorized concurrently (as per contractual agreement) 4. Physician reviewer in conjunction with the provider will authorize quantity, strength, frequency and appropriate medication according to the diagnosis and coverage of benefits. 5. The period of time that authorizations are valid is determined by the UM Committee (in conformance with contracted health plan requirements). This time period is usually 90 days. (for Medi-Cal members, it is the month of eligibility) Upon request authorization for services may be extended for additional 30 days contingent on member eligibility. The provider should be reminded to always check member eligibility at the time of service. 6. Referral/authorization requests may be placed in a pended status until necessary additional information is obtained for the UM Committee to make an appropriate determination. In these Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures 7. situations, the requesting provider will be contacted within 24 hours to obtain the required information. TAR will not be pended longer than mandated time frame. 8. In order to prevent further delay, the UM Committee may approve or deny the request provided adequate information is gathered immediately for a thorough evaluation and an appropriate determination to be made. 9. Requesting providers will be notified immediately of UM Committee referral/authorization determinations. 10. Members will be notified in a timely manner of the determination (e.g., within 24 hours). 11. All denials for service authorization requests will be processed according to AHC IPA policy and procedure (see UM-20 Service Denial) 12. Concurrent review will be conducted in accordance with AHC IPA and contracted health plan approved time frames. The review will be conducted at least the day before the authorized length of stay is complete. 13. On cases where an alternative treatment plan is recommended, the alternative treatment plan and the medical indication/reason for its recommendation and determination is documented on the UM Care Plan form and a copy of which is sent to the requesting provider. 14. Providers, Members, HMOs and other entities will be notified via mail, electronically or by telephone and communication will be documented Urgent Care: Urgent care requires immediate action. Although it may not be life-threatening circumstances, an urgent care condition has the potential to become an emergency in the absence of treatment. Care 1st members needing urgent care will be seen within 48 hrs upon request. Seniors and Persons with Disability - SPD AHC IPA UM department will stamped “SPD” on all SPD member’s TAR. Orientation have been provided to all UM staff that SPD members has a right for continued access for up to 12 months for SPD members requesting Continuity of Care (COC) with a non contracted provider that they have an ongoing relationship with. If non-contracted provider is not willing to accept Medi-Cal fee then member will be assigned to a contracted provider in the network. Note: AHC IPA does not provide centralized telephone services
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Accountable Heath Care IPA Provider Policy and Procedures Emergency services (ER)
Purpose: The UM staff will assist providers and members to follow the proper emergency department service utilization process which is directed at the appropriate authorization of emergency department services. Definition: Emergency care: Emergency services means covered inpatient and outpatient services that are
Furnished by a qualified provider and; needed to evaluate or stabilize an emergency medical condition.
Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severity pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention to result in:
Placing the health of the person (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; Serious impairment to bodily functions; Serious dysfunction of any bodily organ or part; Death
Emergency medical services mean those services for the immediate diagnosis and stabilization of an emergency medical condition, until the condition is stabilized, including pre-hospital care and ancillary services routinely available in an emergency department Urgent Care (for Medicare members). Urgently needed services mean covered services provided when an enrollee is temporarily absent from the Medicare plan’s service area (or continuation area, if applicable), that are immediately required as a result of (1) an unforeseen illness, injury or condition and (2) it is not reasonable given the circumstances to obtain services through the organization offering the Medicare Plan. The key elements of “urgent care,” as defined in Medicare law, are that: (a) the Member needs covered services urgently while out of the service area; (b) to prevent serious deterioration of health; (c) resulting from an unforeseen illness of injury; and (d) for which treatment cannot be delayed until the member returns to the plan’s service area. Policy: 1.
AHC IPAUM staff will provide guidance to providers and members regarding emergency department service utilization. A licensed health care professional is available 24 hours a day, 7
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Accountable Heath Care IPA Provider Policy and Procedures days a week, 365 days a year to direct emergency services. ( Psychiatric emergency condition will be reviewed by Medical Director or behavioral health care specialist) 2.
The UM staff will obtain and document emergency services information for tracking/ authorization process.
3.
AHC IPA covers any emergency services necessary to screen and stabilize members without precertification of emergency services where a prudent lay person, acting reasonably, would believe that an emergency medical condition exist. AHC IPA covers emergency services if a provider or other authorized representative has authorized the provision of emergency services (as described above).
4.
If ER practitioner believes that member may not be discharge safely, AHC IPA will authorize continuation of treatment
5.
AHC IPA will pay all Emergency services triage fee irrespective of emergency care
6.
Non contracted providers are paid for the treatment of emergency medical condition including medical necessary services rendered to a member until the member’s condition has stabilized sufficiently to permit discharge.
7.
AHC IPA will pay ambulance services dispatched through 911
8.
AHC IPA will pay Renal dialysis services that Medicare members obtained while temporarily out of the service area.
9.
AHC IPA UM staff will inform PCP for follow up of emergency care. During business hours, ER room physician will be instructed to inform the member to visit the clinic on the same day.
10.
ER reports and medical records will be obtained from the facility for retrospective review, claim payment and provided to member’s assigned PCP.
11.
Claim payment will not be denied solely on diagnosis. Clinical findings (symptoms) also will be considered for the payment. In the event of life threatening situation (e.g. member is unconscious) where prior approval was not obtained, payment may not be denied.
12.
If an authorized representative of AHC IPA has authorized emergency services, payment will not be denied.
13.
Emergency services (medical screening and stabilization) does not require authorization
14.
AHC IPA will respond to approve or deny post-stabilization care within 30 minutes. If no response within 30 minutes deemed approved.
15.
Non urgent care following an exam in the emergency room – response within 30 minutes or deemed approved
16.
When it is impossible to get the prior approval or where a prior approval process could seriously jeopardize the life or health of the member, request cannot be denied for post service emergency care
Procedure: AHC IPA UM staff receives (or places) calls regarding emergency department service information from AHC IPA contracted providers, emergency department staff and members. These calls may be made
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Accountable Heath Care IPA Provider Policy and Procedures regarding service authorizations at a contracted facility, a non-contracted facility or an out-of area noncontracted facility. A. Calls from Members: 1. If the situation involves the need for immediate emergency care, the member is advised to go to the closest Emergency Facility. 2. If a member needs emergency department services while out of the AHC IPA’s area of service, he/she is encouraged to visit a facility that has a contract with the member’s health plan. If it is appropriate, the member is encouraged to be seen at an Emergency Care Clinic. 3. The member is reminded to contact his/her primary care physician. 4. Appropriate information is documented in the member’s file and information is obtained for the generation of an authorization for services or alternative care plan. B. Calls from PCPs, Hospital’s Emergency Department, or Health Plan: 1. UM Staff receives the call (UR Coordinator or UR Nurse). If UR Coordinator receives the call, he/she immediately forwards it to UR Nurse upon verification of member information. 2. UR Nurse then gathers the following information and documented for tracking/authorization determination process: a. Working Diagnosis
Note:
b.
Vital Signs
c.
Chief Complaints and symptoms such as bleeding, chest pain impaired neurological status.
d.
How the member was brought into the Emergency department such as ambulance, paramedics, police transport, or employer, parent, spouse, friend or self transport.
e.
Duration of the condition such as sudden onset or length of days or weeks.
f.
Treatment or services already provided such as suturing, injections, medications, IV fluids, oxygen.
g.
Procedures or tests already conducted such as chest tubes insertion, x-rays, MRI, laboratory work.
h.
Actual or suggested type of discharge from the Emergency Department such as hospital admission transfer to another facility, discharge home with instructions and follow-up by PCP.
i.
Time and Day of Visit and if visit during primary care physician office hours or afterhours or on the weekend. If the call is after office hours or a non-working day, the physician on call will gather the information above and forwards them to the UR Nurse on the next working day. The UR Nurse will then enter the information in the computer to generate a tracking or authorization number upon verification of member eligibility and benefits. The Medical Director or physician designee on call will review the ER services.
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Accountable Heath Care IPA Provider Policy and Procedures In certain circumstances where member has received emergency services and care stabilized but treating provider believes that it is not safe to discharge the patient, AHC IPA may authorized, take responsibility to treat the patient by another contracted provider or transfer the patient to another hospital who is willing to accept the transfer of the patient. Medical director / hospitalist is available for consultation/discussion. The Medical Director or physician designee is available 24 hours a day, 7 days a week, 365 days a year. Sample Emergency Referral Workflow A.
Member → IPA (UR staff/Physician on call) → Hospital/Other Facility → Notifications to health plan and PCP (within 48 hours)
B.
PCP → Notify IPA → IPA contacts Hospital/Other Facility → IPA notifies Health Plan
C.
Health Plan → Notify PCP/IPA → IPA contacts Hospital/Other Facility → IPA informs PCP to follow up patient after discharge. AHC IPA DOES A RETROSPECTIVE REVIEW OF ER VISITS FOR TRACKING, TRENDING AND ANALYSIS.
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Accountable Heath Care IPA Provider Policy and Procedures Immunization Program - CHDP Overview: The CHDP Program is a preventive well child-screening program for low-income children under 21 years of age. It encompasses the requirements of Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program and the Prenatal Guidance Program. Purpose: AHC IPA shall adhere to the CHDP Programs’ purpose of preventing childhood disability by screening children during critical times of growth and development and making referrals as necessary to improve their health. Policy: Accountable Health Care IPA (AHC IPA) primary care physicians (PCPs) are primarily responsible for administration of immunization to their assigned members. Providers of CHDP services should be certified by the CHDP Program and adhere to the CHDP Program requirements by providing services in accordance with the most recent recommendations of the American Academy of Pediatrics (AAP), the immunization schedule based on joint recommendations of the Advisory Committee on Immunization Practices (ACIP) and AAP, and the guidelines as set forth by the Department of Health Services. Health Screening and Immunization Guidelines Provision of CHDP services may be accomplished through AHC IPA’s providers and/or local health departments and school-based programs in accordance with L. A. Care’s Memoranda of Understanding (applies to Blue Cross and Care 1st). All members 18 months and older are to receive an initial health assessment within 120 days of enrollment. Under 18 months of age IHA is completed within 120 calendar days. Children under 2 years of age should be assessed according to AAP childhood immunization schedule. At the time of any health care visit child should receive necessary immunization. If immunization cannot be given at the time of visit, member must be instructed as how to obtain necessary immunization Comprehensive Health History and Physical Examination AHC IPA’s providers must follow the protocols, guidelines, and procedures provided at the end of this policy. CHDP standards include screening and immunization schedules for specific age groups. The CHDP health screening also includes a comprehensive health history, which collects information on the following areas:
Social/Cultural Environmental Family Health Prenatal, Birth, Neonatal Development Physical Growth
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Accountable Heath Care IPA Provider Policy and Procedures
Nutrition Allergies Illnesses Childhood Injury prevention Accident Hospitalizations Immunizations (Appropriate to age and health history necessary to make status current) Communicable Diseases Health Education
The physical examination must be given while the member is unclothed. Attention therefore should be given to the age of the patient and his/her need for privacy. The physical examination must include, but is not limited to: Skin Hair Head Eyes (Vision Testing)* Ears (Audiometric)* Nose, Throat Mouth, Gums, Dental Screen Blood Pressure Height and Weight
Tobacco Assessment Spine Abdomen Genitals (pelvic exam)* Testicular exam* Extremities Palpation of femoral, brachial and radial pulse Breast Neck Chest
Head Circumference
Lungs
Heart *According to current periodicity tables and CHDP guidelines Tests are to include the following: Lead screening STD screening HIV
Cholesterol screening Tuberculin tests UA or Urine dipstick
Hemoglobin or hematocrit Papanicolaou smear Ova and parasite
Contraception information, unintentional pregnancy information/counseling should be provided to all adolescent age 11 and above. Referral should be made for WIC, CCS, Dental and Vision An appointment shall be made for the member to be examined within two weeks of the request if a request is made for children's preventive services by the member, the member's parent(s) or guardian or through a referral from the local CHDP program. At each non-emergency primary care encounter with members under the age of twenty-one (21) years, the member (if an emancipated minor) or the parent(s) or guardian of the member shall be advised of the children's preventive services due and available from provider, if the member has not received children's preventive services in accordance with CHDP preventive standards for children of the members' age. Documentation shall be entered in the member's medical record which shall indicate the receipt of children's preventive services in accordance with the CHDP standards or proof of voluntary refusal of these services in the form of a signed statement by the member (if an emancipated minor) or the Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures parent(s) or guardian of the member. If the responsible party refuses to sign this statement, the refusal shall be noted in the member's medical record. The confidential screening/billing report form, PM 160-PHP, shall be used to report all children's preventive services encounters. The provider shall submit completed forms to DHS and to the local children's preventive services program within thirty (30) calendar days of the end of each month for all encounters during that month. Provider shall entered in the member's medical record that indicates all attempts to provide immunizations; the receipt of vaccines or proof of prior immunizations; or proof of voluntary refusal of vaccines in the form of a signed statement by the member (if an emancipated minor) or the parent(s) or guardian of the member. If the responsible party refuses to sign this statement, the refusal shall be noted in the member's medical record. Provider shall cover and ensure the provision of a blood lead screening test to members at ages one (1) and two (2) in accordance with Title 17, Division 1, Chapter 9, Articles 1 and 2, commencing with section 37000. The provider shall document and appropriately follow up in blood lead screening test results. Provider shall make reasonable attempts to ensure the blood lead screen test is provided and shall document attempts to provide test. If the blood lead screen test is refused by the member, proof of voluntary refusal of the test in the form of a signed statement by the member (if an emancipated minor) or the parent(s) or guardian of the member shall be documented in the member’s medical record. If the responsible party refuses to sign this statement, the refusal shall be noted in the member’s medical record. Documented attempts that demonstrate the provider’s unsuccessful efforts to provide the blood lead screen test shall be considered evidence in meeting this requirement. Please referral to CHDP provider information notice No 08-10 dated February 4, 2009 for revised guidelines. for childhood lead poisoning and prevention (see attached). VFC program has issued a new guidelines for vaccine storage unit Follow-up on Conditions Identified During CHDP Exam PCPs are responsible for arranging for any medically necessary services identified through a health assessment (or episodic exam). Treatment for these conditions is to be initiated within 60 days. Medical records must contain a justification if disenrollment occurs in the interim. PCPs will coordinate with the CHDP office. WIC: The Woman, Infants and Children (WIC) Special Supplemental Food Program is a federal program that provides specific food vouchers with nutritional value to infants, young children and pregnant women. AHC IPA Medi-Cal members may require the completion of a WIC certificate form, which includes some basic tests. All participating providers should provide such routine care for infants, children and pregnant women upon request including the completion of the certification form. Note:
CHDP providers will be identified at the time of initial application.
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Accountable Heath Care IPA Provider Policy and Procedures
AHC IPA network provider will be informed regarding VFC program via in-service, News letter or Internet
AHC IPA will develop New Vaccine P & P within 60 calendar days of approval by FDA. P & P will be according to Fee-for service Medi-Cal guidelines
Gardasil – Human Papilloma virus Vaccine - HPV vaccine is recommended for 9 to12 yrs old girls, and also for girls and woman age 13 through 26 years of age who have not been vaccinated previously or have not completed the vaccine series are offered vaccination against HPV
PCP is responsible to inform members that Gardasil is a new benefit for woman age 9-26 yrs that are not pregnant and is recommended as part of routine preventive services for women.
CHDP will be offered through school based CHDP program
Provider will complete PM 160 (info) form for CHDP services and keep a log for follow-up if problem identified
Immunization:
2011 Recommended Immunization schedule attached.
Note: All CHDP providers must follow current guideline from California Department of Public Health to participate in CHDP program. (See attached regulation effective July 2009) All providers and UM department will be informed how to access current list of CHDP providers CHDP providers list – web site address: http://www.lapublichealth.org/cms/searchoptionProvider.asp?Keyword=All
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Accountable Heath Care IPA Provider Policy and Procedures
CCS Identification & Referral
Overview: The California Children’s Services (CCS) program provides care coordination services for physically disabled children under age 21 with CCS-eligible conditions or diagnoses. The program’s working hypothesis is that children with complex, disabling conditions receive improved care and achieve better long-term outcomes when services are provided and coordinated through special care centers. Special care centers are located at tertiary medical centers throughout the state and consist of multidisciplinary/multispecialty teams which plan and carry out comprehensive, coordinated care for groups of illnesses, generally based on a particular organ system. Purpose: 1. To identify members with CCS-eligible conditions. 2. To facilitate the referral process and the coordination of care of CCS-eligible members as well as the provision of all primary care and specialty care not related to the CCS-eligible condition of a member. Policy:
AHC IPA will ensure that its contracted providers perform necessary examination and referral to determine a patient’s diagnosis or condition. In accordance with the CCS eligibility criteria, the PCP or specialist physician refers potentially eligible members to the CCS Program for comprehensive case management.
AHC IPA’s CCS Care Coordinator is responsible for members with CCS-eligible conditions and ensures that they are referred to CCS and will do any necessary follow-up.
Initial referrals of Member's with CCS-eligible conditions to be made to the local CCS program by telephone, same-day mail or Fax. The initial referral shall be followed by submission of supporting medical documentation sufficient to allow for eligibility determination by the local CCS program.
CCS reimburses only from the date of referral.
CCS reimburses only CCS paneled providers
If the local CCS program does not approve eligibility, AHC IPA is responsible for the provision of all Medically Necessary Covered Services to the Member. If the local CCS program denies authorization for any service, AHC IPA is responsible for obtaining the service, if it is medically necessary and paying for the service if it has been provided.
AHC IPA’s CCS Care Coordinator will ensures that the member’s contracted health plan’s case manager as well as CCS program is informed if the member may fall into any of the CCS category or of the CCS admission within 24-hours (in the case of weekend or holidays, within 1 day) of identification of each case. AHC IPA will not deny services pending CCS approval or determination.
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Accountable Heath Care IPA Provider Policy and Procedures
PCP will document in the medical record that PCP is aware of members CCS status. When services are covered by CCS eligible members, CCS paneled physician summery report or PCP notes of discussion or results from the CCS provider will be documented in the medical record.. PCP will provide routine health care services including Initial Health Assessment, complete physical examination, periodic examination and preventive health services
In an emergency admission, AHC IPA network physician shall be allowed until the next working day to inform the CCS program about the Member. Authorization shall be issued upon confirmation of panel status or completion of the required process.
AHC IPA staff will give orientation to PCP at the time of Facility Site Review/Medical Record Review. AHC IPA may inform the provider via Newsletter or during general orientation meeting.
Eligibility Criteria: Please refer to a separate Binder. CCS Identification, Referral Procedures and Care Coordination: The following procedures demonstrate AHC IPA’s identification and referral procedures for members with CCS-eligible conditions: Identification:
Through prior authorization requests, AHC IPA’s CCS Care Coordinator will identify members with potential CCS eligible conditions.
Through concurrent review of inpatient services, AHC IPA’s Case Manager will identify any potential CCS eligible condition.
Through initial and on-going assessments done by Primary Care Physician.
Referral
The PCPs are to notify AHC IPA’s CCS Care Coordinator when they encounter a potential CCS client.
The PCPs, with the assistance of the CCS Care Coordinator, will refer potentially eligible member to an appropriate CCS panel provider for confirmation of a CCS eligible diagnosis.
Hospital staffs in the pediatric or neonatal intensive care areas are requested to make direct referrals. A follow-up call to the hospital staff is placed by the CCS Care Coordinator to ensure that the referral is made. CCS Care Coordinator also informs the patient’s health plan case manager for further coordination.
A physician (other than the PCP), public health nurse, teacher, parent, community agency or interested individual may also refer a child to CCS.
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Accountable Heath Care IPA Provider Policy and Procedures Care Coordination The CCS-eligible member’s PCP is the overall case manager for the member. AHC IPA’s CCS Care Coordinator will work with the CCS Case Manager to coordinate the transition of care from its contracted provider to the CCS paneled provider. AHC IPA’s CCS Care Coordinator will continue coordinating the care with the PCP, Health Plan’s case manager, and/or other healthcare provider involved with the overall care and management of the patient. (for In- patient and Out-patient)
Note: Provider will be informed and orientation will be provided annually. UM department will be provided access to the list of current contracted and non-contracted CCS approved provider. Following web site list CCS Providers: http://www.dhcs.ca.gov/services/ccs/Documents/ppn.pdf
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Accountable Heath Care IPA Provider Policy and Procedures
Comprehensive Perinatal Services Program - CPSP
Purpose: To provide pregnant members with a comprehensive, multidisciplinary pregnancy and postpartum services with case coordination including obstetrics, risk assessment/reassessments, health education, nutritional services and psychosocial services in accordance with the standards of the American College of Obstetrics and Gynecology, the Comprehensive Perinatal Services Program (CPSP) specifications of Title 22 of the California Code of Regulations, and the provisions set forth below. Policy: All OB Specialist providers are mandated to do a CPSP assessment on all pregnant Medi-cal members of AHC IPA. In cases where OB provider is not a CPSP approved provider, member may be referred for CPSP assessment. Pregnant members are to be provided comprehensive, multidisciplinary pregnancy and postpartum services with case coordination including obstetrics, risk assessment/reassessments, health education, nutritional services and psychosocial services in accordance with the standards of the American College of Obstetrics and Gynecology (ACOG) and CPSP specifications. The CPSP Initial Combined Assessment, Health Education, Psychosocial, Nutrition form as approved (H2779 761682) by the DHS is to be used. Nutritional counseling (dietitian) and/or psychosocial services should be provided by providers. AHC IPA may refer to another provider if necessary for the coordination services. Each OB Specialty provider is required to submit to the IPA “Prenatal notification report” and “Pregnancy outcome report.” AHC IPA will submit the report to respective health plan on a monthly basis If OB specialist is not a certified provider, member may be transferred to another CPSP certified providers. If member declines the CPSP services, it should be documented in the chart. AHP IPA case manager will log all EDC and actual delivery statistics for utilization purpose and to follow up cases. More over case manager will refer baby to AHC IPA approved Pediatrician Case Coordination: Case coordination will be provided by the obstetric physician or may be delegated to a licensed nurse practitioner or nurse midwife under the supervision of the obstetric physician. Case coordination includes all clinical aspects of care, record keeping and communication, as detailed below:
Orientation
Assessments
Development of written, individualized care plan based on all assessments
Appropriate interventions/treatments provided according to the care plan and approved protocols.
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Accountable Heath Care IPA Provider Policy and Procedures
Continuous assessments of the patient’s status and progress relative to care plan interventions with appropriate revision of care plan.
Case conference or other appropriate communication involving all team members regarding each patient’s care
Maintenance of medical chart where all information relating to patient care is documented according to standards
Provision of information to all contracted health plans
The physician or NP or nurse midwife will complete the CPSP acknowledgement of notification form and will append it to the medical record. The patient must sign the form indicating that they have either accepted or declined the service.
Appointment Scheduling: The First Prenatal Visit is to be scheduled as soon as possible and no longer than one week after a member’s request. If the member is experiencing adverse symptoms, the time frame for the first prenatal visit may need to be shorter than one week based upon the symptoms described. If the patient misses the first prenatal visit, the provider must immediately follow up with a phone call. If there is no phone response, a letter must be sent to the member within one week of the missed appointment. Continued inability to reach the patient within two weeks must be referred to the Case Manager and member’s health plan Case Manager for follow-up assistance. Return visit frequency should be determined by a member’s individual needs and risk factors. Generally, a member with an uncomplicated pregnancy should be seen every 4 weeks for the first 28 weeks of pregnancy, every 2-3 weeks until 36 weeks gestation and weekly thereafter. If the member has active medical or obstetrical problems, return visits should be more frequent as determined by the nature and severity of the problems. The Postpartum Evaluation must be scheduled four to six weeks after delivery. Orientation: Orientation is the time information is given to the patient of the various types of services that will be provided to her. Orientation is usually done during the initial assessment but can also be done later inn the pregnancy, e.g. to describe a procedure such as amniocentesis, or to provide a hospital tour. All orientation shall include the following:
Types of services such as medical procedures, health education, nutrition, and referrals. Schedule of services Team of caregivers Where services are provided Appointments and procedures Emergency procedures Client rights and responsibilities Document orientation
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Accountable Heath Care IPA Provider Policy and Procedures
Patient handouts/pamphlets
Individual Care Plan (ICP): The Individual Care Plan (ICP) is developed from information obtained during the initial assessment. The ICP contains the actions the Provider and the client plan together to address her concerns. The ICP is developed with the client, not for her. For the most part, it should reflect her perception of her needs and priorities. It may also include referrals to outside agencies. Referrals should include the name of the agency, contact person, and phone number. The required elements of the ICP are as follows:
Risk conditions and problems. The obstetric, nutrition, psychosocial and health education assessments establish a history for the client during the interview process. Interventions. Teaching, counseling, referrals, problem solving, and any actions to be taken by the client or staff to assist in the resolution of risk conditions/problems are examples of interventions that should be noted in the ICP. All proposed interventions should take into consideration the client’s cultural background and linguistic needs. Client Outcomes. Documentation of the results of interventions or actions taken by the provider and/or client is an example of outcome information. At a minimum, update the plan after each reassessment, indicating the progress achieved to date and any modifications of the plan that may be necessary.
First Prenatal Visit Protocols: The first prenatal visit must include the following services:
Comprehensive history. Includes family, genetic, and obstetric history, medical/surgical history, dietary intake, tobacco/alcohol/drug use, risk factors for intrauterine growth retardation and low birth weight, prior genital herpes lesions, psychosocial evaluation. Complete physical examination. Includes complete pelvic examination (with pap smear), height, weight, blood pressure, pulse, breast exam, system exam (skin, heart, mouth, neck, lungs, abdomen, extremities, neurology). Laboratory/Diagnostic Procedures. Includes blood pressure, hemoglobin and hematocrit, ABO/RH typing, Rh(D) and other antibody screen, VDRL/RPR, Hepatitis B surface antigen, Urinalysis for bacteriuria, Gonorrhea culture. Counseling. Includes proper nutrition, tobacco/alcohol/drug use, safety belts, and health education related to pregnancy danger signs. If the patient is determined to be high risk in the appropriate area, the following may also be required: Hemoglobin electrophoresis, rubella antibodies, chlamydial testing, counseling/testing risks regarding HIV infection, discussion of amniocentesis.
Reassessment of Follow-up Protocols: Each follow-up visit must include evaluation of the following: weight, blood pressure, fundal height, edema, abdominal examination for fetal size and position (Leopold’s maneuvers), fetal heart tones, urine for glucose and protein, nutritional counseling, patient complaint, interval history. Specific screening tests and counseling are recommended at the following gestational ages:
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Accountable Heath Care IPA Provider Policy and Procedures
8-18 weeks: Ultrasound (if indicated), amniocentesis (if indicated), chorionic vilus sampling (if indicated)
16-18 weeks: Maternal serum alpha-fetoprotein, tobacco use, alcohol and other drug use, ultrasound cephalometry
By 27 weeks: Reassessment of nutritional, psychosocial, and health education needs (revise Individual Care Plan as indicated)
26-28 weeks: Diabetes screening, repeat hemoglobin or hematocrit (if indicated)
28 weeks: Repeat antibody test for unsensitized Rh-negative patients, prophylactic administration of Rho (D) immune globulin
32-36 weeks: Ultrasound (if indicated), repeat testing for sexually transmitted infections (if indicated), family planning counseling/plan
By 39 weeks: reassessment of nutrition, psychosocial, and health education needs (revise ICP as indicated), inquiry related to member’s plan for pediatric services/provide information about CHDP program
Postpartum Visit Protocols: The postpartum visit (4-6 weeks after deliver) must include the following:
Interim History and Physical Examination. Includes weight, blood pressure, nutritional assessment, breast examination, complete rectovaginal evaluation, examination of episiotomy and repaired lacerations including the adequacy of pelvic and perinatal support, examination of uterus and adnexa, health education. Review of family planning and contraceptive practices. Discuss infant feeding Consider general disorders, such as psychosocial, backache, and depression Laboratory testing as indicated. Includes complete blood count if patient was anemic upon hospital discharge or has been bleeding during the puerperium.
Intervention: Risk Assessment: An initial comprehensive risk assessment (including obstetrics, health education, psychosocial and nutrition) will be provided at the first prenatal visit. Risk re-assessment will occur every trimester, and at the postpartum evaluation. The following issues/problems should be considered during risk assessment:
Pregnancy Conditions/Issues: Unintended or unwanted pregnancy, teenage pregnancy, fear of physicians, hospitals, and medical personnel, language barriers, lack of basic reproductive awareness, housing and transportation problems, no previous contact with health care systems, multiple gestation, need for bed rest during pregnancy, previous receipt of unfriendly health care services, personal and religious beliefs at odds with optimal perinatal care. Postpartum Conditions/Issues: Postpartum blues, postpartum depression, housing, food, transportation problems, lack of basic parenting skills and role models, breast-feeding difficulties, sexual pain/difficulties, severe anemia.
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Accountable Heath Care IPA Provider Policy and Procedures
Medical Issues: Diabetes, hypertension, Hepatitis, HIV infection, genetic problems, epilepsy or neurological disorder, renal disease, alcohol or drug abuse, maternal cardiac disorders, thyroid or other endocrine disorders. Members with any of these conditions must be referred to a medical specialist. Social Issues: Family abuse, psychiatric problems, chemical abuse, financial problems. Member with these issues must be referred to a social worker. Dietetic/Nutrition Issues: Poor nutritional status, daily diarrhea, very overweight (=>135%), underweight (=8 lbs/month), inadequate weight gain (25) and have another risk factor for diabetes.,
At least every 2 years. Every 3 years, if hyperlipidemia or hypertension present or if overweight (BMI >25) and have another risk factor for diabetes., Starting at 45 years, every 3 years.,
At least every 2 years. Every 3 years.
height, weight, BMI, screening tor tobacco use)
Blood Pressure Type 2 Diabetes
Routinely.
Hearing and Vision Difficulties Screenings Fecal Occult Blood
Every 1 to 2 years.
If at high risk. If at high risk. Routinely.3 Annually, if at high risk.3 Discuss if at increased risk for coronary heart disease.
Starting at age 50, every 1 to 2 years. Starting at age 50, every 5 years. Starting at age 50, every 10 years. If at high risk.2 If at high risk. Routinely.3 Annually, if at high risk.3 Discuss if at increased risk for coronary heart disease.
Provide tobacco cessation interventions as appropriate. Counsel parents who smoke about harmful effects of smoking on children's health. If hyperlipidemia present and other known risk factors for cardiovascular and diet-
Provide tobacco cessation interventions as appropriate. Counsel parents who smoke about harmful effects of smoking on children's health. If hyperlipidemia present and other known risk factors for cardiovascular and diet-
Provide tobacco cessation interventions as appropriate. Counsel parents who smoke about harmful effects of smoking on children's health. If hyperlipidemia present and other known risk factors for cardiovascular and diet-
Sigmoidoscopy Colonoscopy Tuberculosis Screening Syphilis Screening HIV Screening
Aspirin Chemoprevention
Behavioral counselling Tobacco Use Secondhand smoke
Intensive dietary counseling
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Every 5 years. Every 10 years. If at high risk.2 If at high risk.
Discuss if at increased risk for coronary heart disease.
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Accountable Heath Care IPA Provider Policy and Procedures Intensive counseling and behavioral intervention to promote weight loss Alcohol Misuse Accidental Injury
related chronic disease. If obese (BMI > 30)
related chronic disease. If obese (BMI > 30)
related chronic disease. If obese (BMI > 30)
Screen and counsel behavior to reduce misuse Counsel as appropriate for age
Screen and counsel behavior to reduce misuse Counsel as appropriate for age
Screen and counsel behavior to reduce misuse Counsel as appropriate for age
Recommended Preventive Services for Adult Males Screening / Test
22-39 years
40-64 years
65 Years and Older
Total Cholesterol with HDL CholesterolProstate Specific Antigen (PSA)
Starting at age 35 every 5 years. Earlier if at high risk
Every 5 years
At your discretion
Starting at age 50 at your discretion. Starting at age 45 if at high risk
At your discretion
Abdominal Aortic Aneurysm Screening (AAA)
Once between 65-75 yers if ever smoked
Recommended Preventive Services for Adult Females Screening / Test
22-39 years If at high risk.
Starting at age 45, every 5 years. Earlier if at high risk.
Total Cholesterol with HDL Cholesterol Breast Self-Exam/Breast Self-Awareness Clinical Breast Exam Mammogram Pap Smear with Pelvic Exam
Chlamydia Screening
Gonorrhea Screening Rubella Antibody Screening
65 years and older At your discretion.
Optional
Optional.
Optional.
Every 3 years.
Every year. Every year. Every 1 to 3 years if two previous consecutive results are negative (normal).
Every year. Every year. Every 1 to 3 years if two previous consecutive results are negative (normal). At age 70 and older at your
Annually until age 30." After age 30, every 1 to 3 years if two previous consecutive results are negative (normal). All sexually active females 25 years and younger and other females at high risk. All sexually active females, if at high risk. Once before 1st pregnancy.
Osteoporosis Screening
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40-64 years
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discretion.' If at high risk.
If at high risk.
Starting at age 60, if at high risk.
Every 2 years
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Accountable Heath Care IPA Provider Policy and Procedures
Recommended Preventive Services for Pregnant Females Screening I Test Chlamydia Screening Asymptomatic Bacteriuria Screening Gonorrhea Screening Hepatitis B Virus Screening HIV Screening
If 25 years and younger. Women older than 25 years, if at high risk. Between 12 and 16 weeks' gestation. At 1st prenatal visit, if at high risk. Repeated screening, if at high risk. At 1st prenatal visit. Screening should be included in routine panel of prenatal screening tests. Repeat screening at 3n1 trimester, if at high risk. At 1st prenatal visit.
Syphilis Screening Rh (0) Incompatibility Screening
At 1st pregnancy-related visit. Repeated screening, at your discretion.
Gestational Diabetes Breast feeding education and promotion Tobacco Cessation
Assessment at 1,' prenatal visit. Testing between 24 and 28 weeks of gestation, if at high or average Structured breast feeding education and behavioral counseling program to promote breastfeeding Provide 5-15 minutes smoking cessation and self-help material
Preventive Service Guidelines for Children and Adolescents Assessment/Screening Regular Check-up (history, physical exam, growth and developmental check, vision and hearing assessment, tobacco assessment. and health education)
Birth -12 months At birth, between 2 and 4 days, 1, 2, 4, 6, 9 and 12 months
At 3 and 4 years
Blood Pressure Visual Acuity Test (snellen) Audiometric Testing Hematocrit or Hemoglobin
15 months - 4 ears At 15, 18 and 24 months, 3 and 4 years
At 3 and 4 years At 3 and 4 years Once between 9 and 12 months, preferably at 9 months
Between 13 to15 months and at 2 and 3 years
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At 5, 6, 8 and 10 years At 5, 6, 8 and 10 years At 5, 6, 8 and 10 years Every 2 to 3 years
At 5 years and every 2 to 3 years
Urine Dipstick or Urinalysis
TB Exposure Risk Assessment
5 years -10 years At 5, 6, 8 and 10 years
At 1, 2, 4, 6, 9 and 12 months
At 15, 18 and 24 months, 3 and 4 years
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At 5, 6, 8 and 10 years
11 yrs - 21 years Annually
Annually At 12, 15, and 18 years At 12, 15. and 18 years Once, preferably at 13 years. Annually for menstruating females. Once, preferably at 16 years. Annually for sexually active males and females. Annually
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Accountable Heath Care IPA Provider Policy and Procedures Tuberculin Test
At 12 months (if at high risk)
At 15, 18, and 24 months, 3 and 4 years (if at high risk)
Blood Lead Risk Assessment
At 6, 9, and 12 months
Blood Lead Test Cholesterol Screening
At 12 months
At 15, 18 and 24 months, 3 and 4 years At 24 months At 24 months, 3, and 4 years (if at high risk)
At 5, 6, 8 and 10 years (if at high risk)
Annually (list high risk)
At 5, 6, 8 and 10 years (if at high risk)
Annually (if at high risk)
Pelvic Exam
STD Screening (includes Chlamydia) Dental Health (exam by doctor)
Annually for sexually active females. Pelvic exam and pap smear recommended between 18-21 years for all females.
Once between 12 months and 3 years, preferably at 3 years
Once between 12 months and 3 years, preferably at 3 years
Anticipatory Guidance Injury Prevention, Violence Prevention. Nutrition Coun--seling Sleep Positioning Counseling
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Birth - 12 months At birth. between 2 and 4 days. 1, 2, 4. 6, 9 and 12 months
15 months - 4 years At 15, 18 and 24 months. 3 and 4 years
As recommended by a dentist
Annually if sexually active. As recommended by a dentist
5 years -10 years
11 years - 21 years
At 5, 6, 8 and 10 years
Annually
At birth, between 2 and 4 days and 6 month
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Accountable Heath Care IPA Provider Policy and Procedures
Medical Record system.
Policy: To maintain, for each member of the Plan, a legible detailed medical record consistent with good medical and professional practice and meets the requirements of the Department of Health Services, Department of Managed Health Care and any other regulatory agencies. Purpose: To make accurate, timely and complete information available to the provider at the time a clinical judgment is being made on the patient. To permit effective internal professional review of all health care services rendered. To facilitate an adequate system for follow-up treatment. To have a medical record that contributes to the health of the patient. To permit effective external medical audit processes. Procedure: Personal Data: The personal data of the patient will contain the following information: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Name Address Telephone number ID Number Date of Birth Sex Marital status Social Security number* Name of nearest relative and telephone number Emergency contact names, address and telephone number.
Problem Record The receptionist will place the problem list on the chart of all new patients. This will contain the patient’s name, the record number and the date of birth. The physician who identifies the problems will complete the list of problems. The problem list will include any problem being dealt with by a physician or any other provider at its highest level of resolution. This will apply to both temporary problems and chronic problems, which when designated as such by the physician, will be recorded in the appropriate box. Significant surgical procedures will also be included on the problem list.
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Accountable Heath Care IPA Provider Policy and Procedures Medication Record The Medication Record will be placed on the chart of each patient. The patient’s name and ID number will be documented on the Medication Record. This record will be filled out by the nurse at the discretion of the physician, with initials of the nurse along with the initials of the attending physician. The telephone number of the pharmacy that will fill the prescription will be placed in the appropriate location on the Medication Record. This record will help the physician to document and follow utilization of all medications. Note: Nurse will make sure that the correct prescription has been given to the patient. It is advisable to inform the patient to bring the filled medication to the clinic for accuracy of filled prescription. In the event of a mistake, pharmacy should be called immediately. Preventive Care Record The preventive care records address the preventive care provided to each pediatric or adult patient. This includes dates of immunizations, lab works as indicated in the preventive care schedules. Each chart must have its own preventive care record. Recording Medical Information at Each Patient Visit The following information will be recorded in the medical record for each patient visit: 1. 2. 3. 4. 5. 6. 7. 8
Date of visit Vital signs: weight, height (of a child), blood pressure (over three years), temperature, pulse, allergy status, and signature of the person performing these procedures Chief complaint/signs and symptoms Follow-up of previous visits Diagnosis or medical impression Tests and/or therapies ordered Treatments, recommendations, referrals, patient instructions, including follow-up care, any prescribed drugs and instructions, and return visit. Signature or clear initials of the practitioner and/or any counter signatures are required at each entry.
Pediatric /Adult Physical Forms The pediatric/adult initial physical exam forms provide documentation of a complete baseline physical exam. The Pediatric and Adult Physical Forms provide a ready access to standardized familiar format for both recording an initial physical and reviewing the physical on subsequent visits. Sometimes a narrative physical exam will accompany the initial physical form being printed out, but the form will serve as a foundation and a reference to which progress note physicals are keyed. The forms are designed so they can easily be completed by checking “normal,” “abnormal” or “not done.” All sufficient physical findings will be described on the form and documented in the progress notes.
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Accountable Heath Care IPA Provider Policy and Procedures Staying Healthy Assessment Forms These forms are filled out by patients during the initial encounter with the primary acre physician or during a complete physical check-up. For children, there are age-specific staying healthy assessment forms to be filled out during each scheduled well baby check-up. The physicians review the forms and educate the patients or parents or guardians, in case of children, depending on their answers. Immunizations Immunization status will be assessed and appropriate immunizations administered by the physician or paraprofessional at the time of the health assessment, unless medically contraindicated or refused by the patient or guardian. Provider is responsible for assuring that all adults are fully immunized. Provider shall cover and ensure the timely provision of vaccines in accordance with the most current California Adult Immunization recommendations. Provider shall cover and ensure the provision of age and risk appropriate immunizations in accordance with the finding of the IHA, other preventive screenings and/or the presence of risk factors identified in the health education behavioral assessment Provider shall documents attempts to provide immunizations. If the Member refuses the immunization, proof of voluntary refusal of vaccines in the form of a signed statement by the Member or guardian of the Member shall be documented in the Member's Medical Record. If the responsible party refuses to sign this statement, the refusal shall be noted in the Member's Medical Record. Documented attempts that demonstrate provider's unsuccessful efforts to provide the immunization shall be considered sufficient in meeting this requirement Medical Chart Organization 1.
Each form or other document must be securely placed in the appropriate section of the chart using the fasteners. No loose papers or removable self-stick notes are to be in the chart; information on these items must be transferred to a progress sheet or other form.
2.
Reports or other documents that are not on standard size paper must be stapled or taped to an 8 ½ x 11 piece of paper and placed in the chart.
3.
If it becomes necessary to start a new volume, label the new chart “Vol. II of II’ and label the old chart “Vol. I of II.” The following items should be carried forward to Volume II: a. b. c. d. e. f.
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Consent to Treat form. Problem Index. Medication Log Preventive care record Most recent History and Physical Form. Pertinent history from previous providers. Page 3 of 9
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Accountable Heath Care IPA Provider Policy and Procedures
g
Most recent Lab, X-ray, EKG and progress note.
Medical Record Documentation Legibly hand writes or dictates clinical SOAP notes: a. b. c. d.
Subjective (S) part of the clinical note is to include the patient's Complaint and history of illness. Objective (O) part of the clinical note is to include the medical provider's examination of the physical findings such as weight, BP, and test results. Assessment (A) pan of the clinical note is to provide the clinical impression or diagnosis based on the S and O information Plan (P) is divided into three parts. (1) (2) (3)
All tests are listed which are pending results (outside labs, x-rays, etc.) and any referrals for diagnostic purposes and old record requests. Describe medications or other treatments prescribed. Health care education, patient education handouts and discussions with the patient regarding treatment objectives.
Record Ownership It is the policy of the Plan that the medical record remains the property of the doctor's office. The medical record may not be removed from the premises without a subpoena or a court order. 1.
Patients wishing to obtain copies of their medical record may do so by completing an authorization for release of medical information form.
2.
Under California law AB-610, patients may review their medical records. The doctor's office has five, (5) working days in which to provide access to the patient to review their medical record, and fifteen (15) days to provide photocopies to that patient.
3.
Nursing personnel and medical staff members will refrain from removing medical record documents from the doctor's office premises. Charts for patient care and committee activity will be checked out.
. 4
Medical record staff will maintain an adequate chart checkout system. Out guides should be utilized to identify records that are checked out of file.
5. Under no circumstances should an original document be mailed to another facility or to a physician's Office. The original document should remain on the premises at all times. Photocopies of the original documents should be made when patients are being transferred to other care facilities or physician offices.
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Accountable Heath Care IPA Provider Policy and Procedures Confidentiality of Patient Records The patient's medical record is regarded as confidential information and will, at all times be protected from loss or tampering. Personal and medical information will not be discussed except by appropriate personnel in a location that assures confidentiality. No one, except authorized personnel in the Primary Provider's office where the patient gets health care services, will have access to patient records. Patient information will not be released without a signed request from the patient or a court order. Patient information will not be given verbally over the telephone unless the inquirer is identified. This ensures that the patient's record is maintained in the strictest confidence and that no Information is released without written permission from the patient. Custody of Medical Records The Office Manager, at each primary care provider's office, is responsible for maintaining a system of collecting, retrieving, distributing, and storing medical records. The Manager will delegate the responsibility to appropriate members of the staff whose job is to prepare patient records for offices, so that they are readily available to the provider's staff. Once the patient has been seen in the office, it will be the ultimate responsibility of the Manager to have the records completed and returned to the appropriate room where the records are stored. The authorized persons are instructed to take the utmost precautions to assure that the records are protected from loss or tampering, This policy reinforces the importance of patient confidentiality by insuring that there is the shortest turn around time for medical record processing and return for storage. Personnel who have access to the medical records will be instructed that the patient records are highly confidential and information Completeness of Medical Records All medical record entries on the chart will be legible and signed. Further, all care received will be adequately documented in the chart. This includes reports on emergency room visits, TAB ambulatory surgeries, hospital discharge summaries, consultation and other reports necessary to evidence continuity of Care. Timeliness of Data Entry The purpose of Timeliness of Data Entry is to set medically appropriate guidelines for medical record data entry that will assure the timely availability of pertinent information. For this purpose the provider will write out all progress notes. Results of laboratory tests performed on site will be available within twenty-four (24) hours, and medical staff is responsible for charting the test. results within this time frame and notifying the physician or office Manager immediately of positive or abnormal test results. Specimens for off-site testing will be forwarded, on a daily basis, to the appropriate laboratory. They will be run on the day of receipt or the following day. Clinic values will be reported to the office by telephone. All results will be sent to the office within twenty-four (24) hours. Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures The medical assistant is responsible for locking all specimens being transported. Follow-up is required if test results have not been returned within the timeframe required by the provider. Reports from appointments made for patients for the purpose of further testing and/or consultation will be available in the office within two (2) weeks following the appointment date, unless the physician requires them earlier, Follow-up will be initiated by the Manager or designated staff person if this time frame is not met for patients whom the physician identified as needing to be tracked. The Office Manager is ultimately responsible for follow-up on other non-routine referrals and records as needed. Entries for hospitalization of patients will also be made if the office has been involved in the admission. Hospital summaries are expected to be received within two (2) weeks of discharge and will be tracked accordingly. Past Medical Records The Office Manager is responsible for requesting all past medical records upon orders of the physician. Requests sent will be entered into a logbook, indicating date mailed. Records are expected to be received within a two- (2) week period. Follow-up is a responsibility of the patient appointment clerk/receptionist if this time frame is not met. Release of patient Information The purpose of the Release of Patient information requirement is to safeguard the office and the patient from negative repercussions resulting from the release of personal and confidential information to unauthorized persons. Where request for any part of a patient's medical record is received, a Release of Information form signed by the patient must accompany the request. The receptionist will pull the patient's Medical record and forward the record along with the request to the patient's physician. The physician will be certain that the patient has appropriately signed a Release of Information, complete the form and indicate if any accompanying notes or lab reports are to accompany the form. The clinic, before mailing any information, will make certain again that a release of information form has been signed and make a note on the release form of the date the records were mailed. All such mailings will be made Certified, Return Receipt Requested. The patient's physician will, at all times, protect the confidentiality of the record and may disclose the identity of the patient only when it is essential. Consent for Treatment The clinic is responsible for insuring that general consent forms are properly completed and signed by all patients. The consent form will be signed on the patient's first visit to the office and filed in the chart. This form will apply to the present and all subsequent visits unless revoked by the patent or his/her legal guardian.
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Accountable Heath Care IPA Provider Policy and Procedures A Special Procedure Consent form will be signed by the patient before any invasive procedures or treatments are performed. Obtaining the informed consent (explanation of risk, benefits and alternative treatment) is the responsibility of the physician. Member will be given sufficient information to make an informed decision regarding the consent to or refusal of any recommended medical procedures. For human sterilization (form PM330) consent must be taken before 30 days prior to treatment. Provider and members must sign and date the form as well as Date of procedure performed should be documented. Obtaining Hospital and Outpatient Records This procedure will provide an effective method of tracking all records that the patient's physician may deem important in developing a treatment plan for the patient. The nurse will ask the patient to sign a "Release of Information” form and enter the appropriate data on the patient's history form indicating that the records have been requested. HIPAA Compliance: Individuallly Identifiable Health Information (IIHI) and Protected Health Information (PHI) must be disclosed according to HIPAA and other applicable confidentiality law. Individually Identifiable Health Information (IIHI) is information that is a subset of health information, including demographic information collected from an individual and:
Created or received by health care provider, health plan, employer, or health care clearinghouse; Relates to the past, present, or future physical or mental health (e.g. outpatient treatment with a psychotherapist) or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; Identifies the individual; or with respect to which there is reasonable basis to believe the information can be used to identify the individual.
Protected Health Information (PHI) means individual identifiable health information that is:
Transmitted by electronic media Maintained in an electronic media Transmitted or maintained in any other form or medium
AHC IPA will establish security measures for IIHI and PHI to the extent required under HIPAA. Any disclosures of IIHI and PHI by AHC IPA are in accordance with HIPAA or other confidentiality laws. In the event of improper use or disclosure of information have occurred, AHC IPA will inform health plans without unreasonable delay. Following information will be provided to the health plan: Revised 1-31-2012
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Names of the individuals whose PHI was involved in the breach; Circumstances surrounding the breach; Date of the breach and the date of its discovery Information breached Any steps the impacted individuals should take to protect themselves Steps taken to investigate the breach, mitigate losses, and protect against future breaches Contact person name and designation who will provide additional information about the breach.
Proper measure will be taken to correct the deficiencies. Note: AHC IPA has compliance officer who will provide orientation and assistance to all network providers to meet HIPAA requirement. *No person or entity will engage in the following: [CA Civil Code 1798.85]
Publicly posting or displaying an individual’s SSN in any manner.
Require an individual to transmit their SSN over the Internet unless the connection is secure or the SSN is encrypted.
Require an individual to use their SSN to access the Internet website unless a password or unique personal identification number or other authentication device is also required
Print an individual’s SSN on any materials that are mailed to the member (e.g., letter authorizing services) unless state or federal law requires the inclusion of the SSN on the document to be mailed.
Seniors and Persons with Disability - SPD AHC IPA and health plan will identify all SPD members and provide eligibility list to the provider. so that they will respect the member choices regarding treatment, services and their ability. The family and friends of the SPD members has a right to fully participate in any discussion or decision regarding the SPD member’s treatments and services. SPD members must receive all necessary information regarding treatment and services so that they may make informed choice. Basic Case Management Services shell be provided by the PCP in collaboration with the AHC IPA and shall include: Completion of the Initial Health Assessment (IHA) and the Initial Health Education Behavioral Assessment (IHEBA) Identification of appropriate providers and facilities such as medical rehabilitation, and support services to meet member care needs. Direct communication between the provider and the member / representative. Revised 1-31-2012
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Member / representative education including healthy lifestyle changes. Coordination of carved out and linked services, and referral to appropriate community resources and other agencies.
AHC IPA will ensure the provision of discharge planning when a member is admitted to a hospital or institution and must include: Documentation of pre-admission status, including living arrangements, physical and mental function, social support, DME and other services in place. Documentation of pre-discharge factors including an understanding of the member condition by the member or their representative including physician and mental function, financial resources and social supports. Documentation of services needed after discharge include: Type of placement member/representative agrees to Specific agency/home recommended by hospital Agency/Home member/representative agrees to Pre-discharge counseling A written summary of the nature and outcome of member / representative involvement in the discharge planning process, anticipated problems in implementing post-discharge plans, and further action contemplated by the hospital / institutions. AHC IPA provider relation staff will provide training on a continuing basis regarding clinical protocols, evidenced-based practice guideline and DHCS developed cultural awareness and sensitivity instruction for SPD beneficiaries to provider offices staff and the providers.
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Test Results
Purpose: To ensure continuity of care when care providers order additional tests, prescriptions, etc., or the need arises to contact patients regarding abnormal laboratory or x-ray tests. Policy:
Contracted laboratory will pick up the specimen on the same day Laboratory will delivery the test result to the provider in a timely manner Member will be informed in a timely manner Provider will review the test result and initial the results. Notification and intervention are documented in the chart
Procedure: I.
A written order by a care provider is recorded in the patient chart.
II.
Contacting the patient: 1. Telephone the patient. a) Record the date and time of call in the chart. b) Record the telephone number used to call the patient. c) Record the information given to the patient. d) Sign your fist and last name and title. 2. Send a Certified letter with a “return receipt requested” to patient if unable to contact by telephone. a) Record the date of letter in the chart b) Record the fact that a letter has been sent. c) Record the information that was sent to the patient. d) Sign your first and last name and title. e) Place copy of the letter in the back of the patient’s chart.
III.
Ensuring the continuity of care. a) If the patient has followed through with the recommendations, the chart should be sent back to the Medical Record Department. b) If the patient has not followed through with the recommendations: 1. Send a Certified letter with a “return receipt requested” to the patient notifying them of the lack of compliance. 2. Record on the chart that a letter has been sent. 3. Record the date letter is sent.
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Accountable Heath Care IPA Provider Policy and Procedures 4. Sign your first and last name and title. 5. File a copy of the letter in the back of the chart. 6. Send copy of letter to Patient Relations Department for follow-up. IV.
When trying to notify a patient of abnormal laboratory values or abnormal x-ray or mammography findings, follow the same steps as listed above. a) Telephone the patient. 1. Record the date and time of call or attempted call to patient. Record the phone number called. Note: At least 3 attempts should be made to contact the patient or a guardian with abnormal results. 2. If the patient/guardian is reached, record the information given. 3. Record the name and relationship (if other than the patient) of the person contacted. 4. Record your first and last name and title. When unable to reach a patient/guardian by phone, always remember to record the telephone number called and whether the line was busy no answer, wrong number, etc. All telephone attempts should be at timely intervals. b) If unable to reach the patient by phone, send certified letter with a “return receipt requested”, to the patient. 1. 2. 3. 4. 5.
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Record the date of letter in the chart. Record the fact that a letter has been sent. Record the information that was sent to the patient. Sign your first and last name and title. Place a copy of the letter in the back of the patient’s chart.
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Missed Appointments
Policy: It is the policy of AHC IPA that all PCPs are required to have a procedure in place for assuring timely and efficient recall of patients who fail to keep scheduled appointments. PCP, PA and Nurse practitioner is responsible to determine whether follow up is necessary.
Procedure: The following is a sample of a “Missed Appointment” protocol that may be implemented by PCPs if no other protocol is currently in place.
On a daily basis, determine whether follow up is necessary and what type of follow-up is necessary. Document this decision in the patient chart, using the “Missed Appointment” stamp.
At the end of each day, a designated staff determines which patients failed to keep their appointments by: 1. Checking the appointment schedule and making a list of all failed appointments. 2. Gathering the pulled charts which was ready for appointments. 3. Using a progress sheet with the latest date or a new progress sheet and stamp the sheet with the “Missed Appointment” stamp. 4. Attach the progress sheet to the medical record and forward to the primary care provider. 5. The provider will review the chart to determine the need for patient recall. 6. The provider will complete the items, as needed on the “Missed Appointment” stamp indicating (a) if follow-up is needed or not needed; (b) letter to be sent; (c) phone call made. 7. The provider will then enter his/her signature. 8. The Medical Assistant will review all charts of those patients who missed an appointment and wait for further orders from the provider. If the patient need follow-up, the M.A. shall try to contact the patient two times by phone. If no results, a recall postcard or letter will be mailed out to the patient’s current address of record. A copy will be filed in the chart. The provider is responsible for final decisions concerning a missed appointment follow-up. Patients being followed-up for reportable conditions shall also be reported to the local health authority. PCP may inform AHC IPA and health plan to contact the patient if need arises.
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Accountable Heath Care IPA Provider Policy and Procedures SAMPLE OF A MISSED APPOINTMENT STAMP:
DATE:_____________
MISSED APPOINTMENT
Cancelled
Failed to Show
New appt date
Follow-up
______ Not Needed ______ As soon as possible ______ Letter mailed date ______ Phoned date Instructions given: _______________________________________________ ___________________________________________ Dr.s signature: _________________________________ M.A.: ________________________________________
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Accountable Heath Care IPA Provider Policy and Procedures
After Hour Call
Purpose: To ensure that AHC IPA members have 24-hour access to healthcare professionals. Policy: All PCP are required to have a 24 hours a day, 7 days a week and 365 days per year a system, where by member can contact the provider at any time if required. PCP may have a pager, answering machine or answering service for the patient to contact. PCP must designate a provider to take all emergencies when he/she is not available for extended period of time.
Procedure: Members who feel they have a situation, which is urgent or emergent, must call his/her assigned PCP. If PCP fails to call back within 30 minutes, member may call AHC IPA office at (562) 435-3333 or tollfree at (888) 743-7529 to be connected to a doctor on call. AHC IPA on call provider may instruct the member to go to the nearest emergency room, prescribe medication or to see the PCP as soon as possible. Member must follow the instruction. After hour answering services or telephone system operator will instruct members that if they feel they have a serious acute medical condition, the patients should seek immediate care by calling 911 or going to the nearest emergency room. After hours calls will be managed by a telephone system or answering service. Telephone logs will be monitored and maintained. Member calls after hours will be documented in the member’s medical record. In the clinic, all telephone encounters will be documented in the member’s medical record. There is access to care after normal working hours for urgent medical events that require attention after hours, which includes 24-hour physician access for
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Advance Directive
Purpose: To provide guidelines for adult members of their right to participate in decisions regarding their own medical care when they become incapacitated. Physicians are to take an active role in assisting patients to understand the benefits of this right and provide them with written information and methods of executing advance directives. Federal law mandates all primary care providers to discuss advance directives with their patients. Policy: In a manner consistent with the Health Care Decision Law, Accountable Health Care IPA will provide information to adult members 18 years and older regarding advance directives. An advance directive is a formal document, written in advance of an incapacitating illness or injury, in which adult members can assign the decision-making for future medical treatments. The two most common forms of advance directives are the living will and Durable power of Attorney for health care Federal and State law prohibits unlawful discrimination in the treatment of patients on the basis of race, sex, age, religion, color, disability, national origin, marital status, sexual orientation genetic information, source of payment or health status (including but not limited to chronic, -ESRD-communicable diseases such as AIDS or HIV positive status). AHC IPA will not refuse any treatment to a member who signs or refuses to complete an advance directive. All participating providers may also have an obligation under the Federal Americans with Disability Act to provided physical access to their office and reasonable accommodations for patients and employees with disabilities. Documentation must be present in the member’s medical record whether or not an individual has executed an advance directive and verifies compliance with these policies and procedure. Provider will document Advance Directives in member’s medial record conspicuously Advance directive information will be provided to health plan or any other provider / agency if required by law or when appropriate. Advance Directive information will be given to all members at the time of initial visit. (By brochure, poster in reception area or any other method appropriate for members). Members have a right to actively participate in decision-making process regarding his/her health care, treatment, and services. (Including clinical trial, any investigation studies or new technology)
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Accountable Heath Care IPA Provider Policy and Procedures Member has the right to be represented by parents, guardians, family members, or other conservators (representative) to manage care or treatment decision when member is incapacitated and unable to do so. (physical and mental limitation) Member or member’s representative has a right to withhold life sustaining treatment or services. Member or member’s representative will be involved in decision about withholding resuscitative services or declining / withdrawing life-sustaining treatment. Health plan, CMS or AHC IPA is not required to provide care that conflict with an advance directive AHC IPA will comply with the state law. Orientation regarding advance directive will be provided to all AHC IPA network providers, their staff and all employees of AHC IPA. Orientation will be given by provider relation staff, QM nurse and/or in the providers meeting
INFORMED CONSENT: AHC IPA expects all participating physicians to understand and comply with applicable legal requirements, as well as to adhere to the policies of the medical community in which they practice and/or hospitals where they admit, regarding informed consent from their patients. It is the physician’s duty to give patients adequate information and be reasonably sure that the patient has understood it before proceeding to treat the patient. Informed consent must include benefits, risks and alternative treatments. Member must sign and date the consent.
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Accountable Heath Care IPA Provider Policy and Procedures
ADVANCE DIRECTIVE ! ( HEALTH CARE DECISION LAW)
PLEASE ASK US
WE WILL PROVIDE YOU DETAIL INFORMATION.
DO NOT HESITATE TO ASK ALL QUESTIONS.
IT IS YOUR HEALTH You have a Right
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Medication Error
Purpose: The purpose of this procedure is that reporting, managing and tracking medication errors are necessary to identify causes of error, provide prompt and thorough healthcare after errors occur, evaluate the severity of errors and to take corrective action to prevent further occurrences Policy: Incidents of medication errors must be reported to the Accountable Health Care IPA to comply with the provider network Risk Management Program. Procedure: 1.
A medication error is when a medication is not administered according to the prescribing provider and according to regulatory policies and procedures.
2.
Medication errors have been categorized and defined as follows: a) Medication Not Administered Medication unavailable Failed to administer medication Patient refused medication Other b) Medication Administered Wrong Dose: Administration of a dose that is greater than or less than the amount ordered by the prescribing provider (or manufacturer's recommendation for over the counter medications). Wrong Medication: Medication that is contraindicated (e.g., known allergy, harmful interaction with existing medications) or an incorrect medication is given to the patient. Wrong Time: Administration of medication more than one (1) hour before or more than one (1) hour after the prescribed administration time. Expired Medication: Administration of a medication that has expired No Informed Consent: Administration of a medication where an informed consent would be required but was not obtained.
3. In order to track and quantify medication errors, they will be reported according to severity as described below: Revised 1-31-2012
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Accountable Heath Care IPA Provider Policy and Procedures Level I (No harm): Incidents would include errors in which there has been verification from a prescribing provider that no harm has resulted to the patient. Level II (Low severity): Incidents would include errors in which a prescribing provider determines that the patient needs increased monitoring as a result of the error and no harm resulted. Level III (High Severity): Incidents in which medical treatment / intervention or hospitalization potential for harm from the error. If harm is caused from the error, it is of a temporary nature. Level IV (Life Threatening): Incidents in which errors result in the patient suffering permanent harm, near-death (e.g. anaphylaxis, cardiac arrest, etc.), and / or death. Incidents of medication error shell be reported to the Accountable Health Care IPA to comply with the Risk Management Program. Findings of risk management activities are reported to the Quality Management Committee for recommendation, action and follow up as indicated. 4.
Medication errors should be reported as close to the time of the incident as possible, but no later than 24 hours after the incident.
5.
Medication errors must be documented in the patients medial record..
6. Reporting, managing and tracking medication errors are necessary to monitor errors by
identifying causes of error, provide prompt and thorough healthcare after errors occur, evaluate the severity of errors and to take corrective action to prevent further occurrences. The Accountable Health Care IPA Risk Management Program's purpose is to reduce the frequency and severity of adverse events through risk identification, evaluation and control and thus minimize loss and contribute to quality care and safety for those associated with the provider network.
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