Quality Improvement Program

Quality: A Key Concept with the HMO Blue Texas Network

Quality improvement is an essential element in the delivery of care and services by HMO Blue Texas participating Physicians/Providers. To define and assist in monitoring quality improvement, the plan focuses on measurement of medical care and service delivered by HMO Blue Texas Network Participating Physicians/Providers against established goals.

In this Section

The following topics are covered in this section: Topic Quality Improvement Program: Overview Support Provided to the Quality Improvement Program Patient Appointment Access Standards Physician Office Review Program Office Review Worksheets Sample Medical Forms Principles of Medical Record Documentation Frequently Asked Questions About On-Site Office Reviews

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Quality Improvement Program: Overview

Objectives of the Quality Improvement Program for HMO Blue Texas

The HMO Blue Texas Quality Improvement Program is an integrated process designed to continually monitor, evaluate and improve the quality of care and service provided by participating Physicians/Providers to HMO Blue Texas members. The HMO Blue Texas Quality Improvement Program benefits our members and HMO Blue Texas participating Physicians/Providers by: • Analyzing population assessments at the local and statewide levels to evaluate the services provided to plan members and determine areas of potential quality improvement • Ongoing monitoring of quality indicator codes (QICs), reflecting unexpected outcomes • Coordinating population-based, statistically significant quality improvement clinical outcome studies involving review of medical records and/or claims data • Participating in results analysis of member and provider satisfaction surveys • Promoting preventive health services, wellness programs and member education • Providing coordination and oversight of the Physician Office Reviews to assist in Quality Initiative studies and credentialing of Primary Care Physicians, OB/GYN Physicians and high-volume Specialty Physicians • Defining standards, measuring against established goals, and furnishing informative, constructive feedback to the network health care professional • Monitoring high-volume/high-risk and chronic care services • Implementing and monitoring the adherence to clinical practice guidelines that have been adopted from national organizations for selected high-risk, high-volume and chronic care diagnoses • Investigating and coordinating the resolution of potential quality of care complaints regarding participating Physicians/Providers Continued on next page

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Quality Improvement Program: Overview, Continued

Objectives of the Quality Improvement Program for HMO Blue Texas Continued

• Implementing interventions/initiatives designed to improve the overall health of plan members. Examples include: — Preventive Care/Wellness guidelines — Prenatal Care guidelines — Birthday reminder card for women over 40 years of age, to encourage preventive screenings such as breast self examination, clinical breast examination, Pap smear, mammogram and cholesterol screenings — Outbound calling program and targeted mailing to encourage women to receive mammograms and Pap smears — Medical record documentation tool to help providers track preventive services — New parent packets to encourage timely immunization of children under the age of two years — Childhood immunization reminders at birth, 12 months and 18 months of age to encourage compliance with the childhood immunization schedule —

BCBSTX Web site Healthy Living Section, which provides information related to health and wellness (www.bcbstx.com)

For additional information about the above mentioned interventions or to request samples, please contact the Quality Improvement Program Department: Toll-free at 1-800-863-9798

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Support Provided to the Quality Improvement Program Introduction

The Quality Improvement Program is supported by the HMO Blue Texas Medical Directors, the Statewide Clinical Quality Improvement Committee, Medical Advisory Committees, Network Management Representatives and on-site Physician Office Review (POR) nurses.

HMO Blue Texas Medical Director

• Facilitates communication of quality improvement activities with HMO Blue Texas Physicians/Providers • Serves as a liaison between HMO Blue Texas and HMO Blue Texas participating Physicians/Providers • Chairs the Medical Advisory Committee to facilitate initiatives, including credentialing and review of quality of care issues • Participates in the Quality Improvement Committee, which participates in the development and periodic review of policies, procedures, practice guidelines, clinical criteria, quality initiative outcomes study and initiatives utilized in the HMO Blue Texas Quality Improvement Program.

Quality Improvement Committee

The HMO Blue Texas Clinical Quality Improvement Committee (CQIC) oversees the development, implementation and evaluation of required quality improvement activities. The committee conducts regularly scheduled meetings, is composed of HMO Blue Texas Physicians/Providers, HMO employees and consumer members from HMO Blue Texas, and is usually chaired by the Medical Director. The Physicians/ Providers are invited to serve on the committee for a period of two years. In accordance with the National Committee for Quality Assurance (NCQA), the committee members review and provide input on issues that are presented to the QI Committee. The specific responsibilities of the committee include: • Review Health Plan Employer Data and Information Set (HEDIS) data • Assess, monitor and evaluate utilization, member complaints, service issues and health plan quality indicators • Review proposed interventions to improve the quality of care and service for HMO Blue Texas members. Continued on next page

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Support Provided to the Quality Improvement Program, Continued Quality Improvement Committee, Continued

• Review policies, procedures, standards and criteria utilized in the Quality Improvement and Utilization Management programs • Recommend corrective action plans when opportunities to improve care or service are identified • Review and provide input on member and Physician/Provider complaints.

Medical Advisory Committee

If performance does not meet the HMO Blue Texas program standards, the Medical Director refers the issue to the designated advisory committee for peer review. This committee recommends corrective action plans when opportunities to improve care and service are identified.

Network • Facilitate adequate access for members to a full continuum of appropriately Management credentialed physicians and other professional providers Representatives

• Coordinate the physician/provider recruitment, servicing and credentialing activities

• Communicate with and provide education for HMO Blue Texas Physicians/ Providers and providers regarding Quality Improvement Program activities.

On-Site Physician Office Review (POR) Nurses

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• Evaluate the documentation of care provided in the physician’s office by performing office visits for the Physician Office Review Program. Also perform medical record review for Quality Improvement studies and HEDIS data collection.

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Patient Appointment Access Standards

Standards

HMO Blue Texas has established the following appointment access standards:

Access Measure

Primary Care Physician (PCP)

Emergency Care

Perform immediate triage during office hours and have a method for directing patients to alternative care after hours

100%

Method for handling immediate triage during office hours and for directing patients to alternative care after hours

Urgent Care

Within 24 hours

90%

Within 24 hours

Symptomatic Non-Urgent Care

Within 5 days

90%

Within 5 days

Annual Physical Exam

Within 30 days

90%

Not Applicable

Initial New Patient Visit

Within 30 days

90%

Within 30 days

In-Office Wait Time

Within 30 minutes

90%

Within 30 minutes

After Hours Access

Immediate

100%

Not applicable

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Performance Goal

Specialty Care Physician (SCP)

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Patient Appointment Access Standards, Continued

Definitions

• Emergency Care: Health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity including, but not limited to severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the person's condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in: — — — — —

placing the patient's health in serious jeapordy serious impairment to bodily functions serious dysfunction of any bodily organ or part serious disfigurement or in the case of a pregnant woman, serious jeapordy to the health of the fetus.

• Urgent Care: Medical care for a non-life threatening, but symptomatic condition which, if untreated within 24 hours, could lead to a potentially harmful outcome. • Symptomatic Non-Urgent (Routine) Care: Medical care for a patient with symptoms which are not emergent or urgent. • Annual Physical Exam: Wellness exams for adults or children/adolescents. • Initial New Patient Visit: A “get acquainted” visit with PCP or initial SCP visit for non-urgent symptoms. • In-Office Wait Time: The average number of minutes the member must wait from the scheduled appointment time until the time the member is seen by the physician. • After Hours Access: 100% of PCPs will have a verifiable mechanism in place for directing patients to alternative after hours care based on the urgency of the patient’s need. Mechanisms may include: answering service; recorded message that directs patient to alternative provider, if applicable; or other contact number for immediate response. The performance goals are monitored through the Physician Office Review (POR) program, member satisfaction surveys and complaints.

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Physician Office Review Program

Scope of the Physician Office Review Program

HMO Blue Texas recognizes Physicians/Providers as participants in the health care improvement process. One of the main objectives of the Quality Improvement Program is to provide physicians and other providers with meaningful and constructive data to improve their practice patterns as necessary. Evaluating the care provided in the physician’s office focuses on documentation of clinical care, as well as the structural aspect of care. The following structural aspects of care delivered in the physician’s office are evaluated in the Physician Office Review: • • • •

Safety and environment Medical record documentation Laboratory services Radiology services

These sample forms can be copied for use: QIP-I Office Review Worksheets (G — 11 through G — 15) QIP-II Medical Record Review (G — 16 through G — 19) QIP-IV Adult and Pediatric Sample Chart Tools (G — 20 through G — 37)

Goals of the Office Review Program

• Use objective guidelines to monitor the structural and medical record-keeping practices for clinical aspects of the quality of care delivered in the physician’s / provider’s office • Provide a practical approach for evaluating and improving the care delivered in an office setting • Involve physicians in the improvement process by offering appropriate feedback • Utilize the results of the program in the ongoing managed care contract renewal process Continued on next page

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Physician Office Review Program, Continued

Safety and Environment Component

The primary objective is to assist in ensuring that patient care is accessible, provided in a safe and hazard-free environment and that the office site provides comfort and privacy for the patient. A physician’s staff is expected to maintain office procedures that safeguard against such risks as exposure to infectious disease, theft, abuse or accidental use of drugs and faulty or contaminated patient care equipment.

Laboratory Services Component

The primary issue concerning provision of lab services is the accuracy of test results, which can be affected by such factors as training of personnel, equipment maintenance and calibration, and expiration date of testing reagents. The Clinical Laboratory Improvement Amendment (CLIA) requires that all laboratories be certified by the Department of Health and Human Services as meeting minimum performance specifications. Evidence of CLIA certification is required to meet HMO Blue Texas review criteria as well as state of Texas requirements.

Radiology Services Component

Issues associated with radiology services include calibration and maintenance of equipment, exposure to radiation, film quality and staff training. The state of Texas requires inspection of radiology equipment every three years and documentation of the training for operation of the equipment. The physician is required to register the equipment with the state, which grants a certificate of registration. Following each inspection, a letter of compliance is issued. This review is limited to the radiology services component.

Medical Recordkeeping Practice Component

The organization and adequacy of medical recordkeeping is assessed in order to assure patient confidentiality and consistency of documentation practices. One to five medical records are evaluated at each office site of potential network Primary Care Physicians and OB/GYNs prior to initial credentialing and ad hoc reviews are conducted after initial credentialing review, as appropriate. Continued on next page

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Physician Office Review Program, Continued

Medical Record Documentation Component

Documentation of all significant clinical information pertaining to a patient is critical for continuity and coordination of care and HEDIS data collection. Complete documentation of the patient’s care is a tool in the assessment of care provided. The medical record serves as a primary source for evaluating the appropriateness and cost-effectiveness of care, in addition to serving as important evidence in the event of litigation. The medical record documentation review consists of three to ten medical records at each office site during focused ad hoc reviews of Primary Care Physicians and specialists.

Frequency of the Office Review

The Physician Office Review (POR) Program includes a review of all office facilities of all Primary Care Physicians and OB/GYNs who initially contract with the HMO Blue Texas Network. If a physician fails to meet the expected performance goal on any component of the Physician Office Review, a re-review is conducted every six months until the physician meets the expected performance goal. An ad hoc review may be conducted if there is an indication that a potential quality of care concern exists. A high number of member complaints, a high rate of member turnover or utilization outlier status are examples of such concerns.

Feedback to Physicians on the Office Review

The Physician Office Review Program is designed to foster continuous quality improvement. At the time of the office review, the reviewer will offer to conduct an exit interview with the physician or designated staff to discuss the findings. Copy(s) of the Physician Office Review Summary forms, which identify both positive and negative review findings and offers constructive suggestions for improvement, are left with the office staff upon completion of the Physician Office Review. Additionally, a letter is mailed to the physician, which includes his/her percent compliance as compared to his/her peers. A follow-up visit will be scheduled and a corrective action plan requested from the physician in order to re-evaluate the status of any recommended improvements, as indicated. The HMO Blue Texas Medical Director evaluates any significant issues and recommends action, if necessary. A copy of the review and all associated correspondence is maintained in the physician’s file for consideration by the Medical Advisory Committees at the time of recredentialing.

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Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company★ HMO plans offered by: Southwest Texas HMO, Inc.★ d/b/a HMO Blue ® Texas ★Independent Licensees of the Blue Cross and Blue Shield Association Rev. 10/01

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Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company★ HMO plans offered by: Southwest Texas HMO, Inc.★ d/b/a HMO Blue ® Texas ★Independent Licensees of the Blue Cross and Blue Shield Association

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★Independent Licensees of the Blue Cross and Blue Shield Association

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company★ HMO plans offered by: Southwest Texas HMO, Inc.★ d/b/a HMO Blue® Texas

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Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company★ HMO plans offered by: Southwest Texas HMO, Inc.★ d/b/a HMO Blue® Texas

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Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company★ HMO plans offered by: Southwest Texas HMO, Inc.★ d/b/a HMO Blue® Texas

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Principles of Medical Record Documentation

Introduction

The following Principles of Medical Record Documentation have been developed jointly by representatives of the American Health Information Management Association, the American Hospital Association, the American Managed Care and Review Association, the American Medical Association, the American Medical Peer Review Association, the Blue Cross and Blue Shield Association, and the Health Insurance Association of America. Although their joint development is not intended to imply either endorsement of or opposition to specific documentation requirements, all seven groups share the belief that the fundamental reason for maintaining an adequate medical record should be its contribution to the high quality of medical care.

What is Documentation and why is it Important?

Documentation is the recording of pertinent facts and observations about an individual’s health history, including past and present illnesses, tests, treatments and outcomes. The medical record chronologically documents the care of the patient in order to: • Enable Physicians/Providers to plan and evaluate the patient’s treatment; • Enhance communications and promote continuity of care among Physicians/Providers involved in the patient’s care; • Facilitate claims review and payment; • Assist in utilization review and quality of care evaluations; • Reduce hassles related to medical review; • Provide clinical data for research and education; and • Serve as a legal document to verify the care provided (e.g., in defense of an alleged professional liability claim). Continued on next page

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Principles of Medical Record Documentation, Continued

What are Medically Necessary Services?

Typically, payers define medically necessary services as those services or supplies that are: • In accordance with standards of good medical practice; • Consistent with the diagnosis; and • The most appropriate level of care provided in the most appropriate setting. Note that the definition of medical necessity may differ among insurers. Medically necessary services may or may not be covered services depending on the benefit plan.

How does the Documentation in Your Medical Record Measure Up?

1. Is the reason for the patient encounter documented in the medical record? 2. Are all services that were provided documented? 3. Does the medical record clearly explain why support services, procedures and supplies were provided? 4. Is the assessment of the patient’s condition apparent in the medical record? 5. Does the medical record contain information on the patient’s progress and on the results of treatment? 6. Does the medical record include the patient’s plan for care? 7. Does the information in the medical record describing the patient’s condition provide reasonable medical rationale for the services and the choice of setting that are to be billed? 8. Does the information in the medical record support the care given in the case where another Physician/Provider must assume care or perform medical review? Continued on next page

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Principles of Medical Record Documentation, Continued

Principles of Documentation

1. The medical record should be complete and legible. 2. The documentation of each patient encounter should include: the date; the reason for the encounter; appropriate history and physical exam; review of lab, X-ray data and other appropriate ancillary services; assessment; and plan for care (including discharge plan, if appropriate). 3. Past and present diagnoses should be accessible to the treating and/or consulting physician. 4. The reasons for and results of X-rays, lab tests and other ancillary services should be documented or included in the medical record. 5. Relevant health risk factors should be identified. 6. The patient’s progress, including response to treatment, change in treatment, change in diagnosis and patient non-compliance, should be documented. 7. The written plan for care should include, when appropriate: treatments and medications specifying frequency and dosage; any referrals and consultations; patient/family education; and specific instructions for follow-up. 8. The documentation should support the intensity of the patient evaluation and/or the treatment, including thought processes and the complexity of medical decision-making. 9. All entries to the medical record should be dated and authenticated. 10. The CPT/ICD-9 codes reported on the health insurance claim form or billing statement, should reflect the documentation in the medical record.

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Frequently Asked Questions About On-Site Office Reviews Why does HMO Blue Texas Need to do Office Reviews?

HMO Blue Texas has a responsibility to our members to help ensure that their care is provided in a safe, professional environment, and that medical records are maintained in such a way as to document care provided and to promote appropriate continuing care. Office reviews comply with standards set by the National Committee of Quality Assurance (NCQA) and the requirements of the Texas Department of Insurance (TDI).

Are we Obligated to Allow this Review?

Yes, according to the contract the physician signed, HMO Blue Texas will have access, at reasonable hours and times, to the treatment and billing records of members in order to verify claims information, and to review other records necessary for verifying compliance with the terms of the agreement, i.e., practice standards for quality and utilization.

How Long Will the Review Take?

The office and medical record review will take approximately one hour. If lab and/or X-ray services are provided, the review will take longer.

What do we Have to do to be Ready?

Pull five HMO Blue Texas member medical records as requested in the confirmation letter provided prior to the review date.

For Primary Care Physicians and high volume specialists, the medical record review will take longer because of the additional questions.

Have one person from the office available to tour the office with the reviewer and to be available for information, if needed. Continued on next page

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Frequently Asked Questions About On-Site Office Reviews, Continued What Happens if We get a bad Review?

The review is not a pass/fail type of review. If deficiencies are found, suggestions will be made to the provider to promote quality improvement. It is feasible that a re-review would be performed after a certain time period to allow for the deficiencies to be corrected.

Will the Results Yes, all results will be kept confidential from other Physicians/Providers. Be Kept Results of the on-site review will be included in the provider’s Confidential? recredentialing file.

When will the Review be Scheduled? Who will do the Review?

Does the Doctor Need to be Available?

The on-site review will be scheduled at a mutually convenient time for your office manager and On-Site Review Specialist.

Time of Audit

PCP

High Volume Specialists

OB/GYN*

Initial Credentialing

Clinical or Non-clinical Personnel

N/A

Clinical or Non-clinical Personnel

Ad hoc

Clinical Personnel

Clinical Personnel

Clinical Personnel

No, the physician can schedule patients routinely; however, one office person should be available to accompany the reviewer on a tour of the office and be available for questions.

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