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    Provider Manual Chapter 11, Page 1 of 9

    Chapter 11. Quality Management

    11.1 Purpose ______________________________________________ 311.2 Primary Objectives _____________________________________ 311.3 Quality Management Council _____________________________ 3

    11.3.1 Annual Plan..................................................................................................... 411.3.2 Quality Improvement Projects ........................................................................ 4

    11.4 Key Service Indicators __________________________________ 511.5 Medical Advisory Committees ____________________________ 511.6 Complaints About Quality or Accessibility of Care ____________ 6

    11.6.1 Referral ........................................................................................................... 611.6.2 Investigation.................................................................................................... 711.6.3 MAC Review .................................................................................................. 7

    11.7 Provider Responsibilities_________________________________ 811.8 Peer Review Protections _________________________________ 8

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    11.1 Purpose

    The purpose of the Mountain State Quality Management Program (QMP) is topromote objective and systematic monitoring, evaluation and continuousimprovement in the quality of:

    Health plan services to members, groups, providers and other internal andexternal customers; and

    Healthcare services that members receive from network and non-networkproviders.

    11.2 Primary Objectives

    The model for the QMP is one of continuous quality improvement of the keyservices and processes that affect health plan members, employer groups andother clients, network providers and other areas of the company (includingaffiliated entities).

    The primary objectives of the QMP are to:

    Promote the provision of quality and timely services by Mountain State andany organizations to which it has delegated functions;

    Promote the accessibility to and delivery of quality healthcare services byproviders to health plan members;

    Address complaints from members, groups, providers and other stakeholders,using such complaints to identify potential areas for process improvement;

    Ensure ongoing compliance with regulatory and accreditation standards; and Instill a corporate culture in which management and staff at all levels

    continuously look for ways to improve the quality of services delivered.

    11.3 Quality Management Council

    The Quality Management Council (QMC) coordinates the Mountain StateQMP. Located within the Health Services Department, the QMC reports throughthe companys senior executive management to the Mountain State Board ofDirectors.

    The membership of the QMC includes representation of all Health ServicesDepartment functions that impact external and internal customers. These include,but are not limited to: utilization management, care and case management,credentialing, medical policy, clinical appeals, referrals, provider relations,

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    network management, clinical quality improvement, disease management, patientsafety, operational quality improvement, and provider contracting andreimbursement methodologies. The QMC also incorporates information fromother areas such as customer service, claims, sales and marketing.

    A Mountain State medical director is the senior clinical staff person involved onthe QMC for any judgments about clinical aspects of performance. In addition,the medical director facilitates input into the QMP from network providers whoserve on Mountain States Credentials Committees, Medical AdvisoryCommittees and Provider Advisory Committee.

    11.3.1 Annual Plan

    Through development of an annual plan, quarterly progress reviews and year-endprogram evaluation, the QMC approves the quality improvement projects andpriorities for each year, oversees their progress and evaluates the results.

    As part of this process, the QMC reviews the performance and adequacy ofmechanisms to respond on an urgent basis to situations that may pose animmediate threat to the health or safety of consumers.

    The annual plan also encompasses activities to ensure ongoing compliance withregulatory and accreditation standards, and to ensure that entities to whichfunctions have been delegated perform services in accordance with contractual,regulatory and accreditation requirements.

    11.3.2 Quality Improvement Projects

    The quality improvement projects approved each year by the QMC will focus onimproving the quality of services and care to Mountain State members, groups,providers and other stakeholders. Generally, projects will relate to the keyprocesses and goals of the Health Services Department (e.g. accessibility andavailability of quality healthcare services, utilization management, casemanagement, improvement of clinical quality of care furnished to plan members).

    The Mountain State QMC may collaborate with Highmarks Quality ManagementDepartment in the development, implementation and evaluation of qualityimprovement projects and activities related to the senior population enrolled inFreedomBlue Medicare Advantage PPO plans.

    To the extent possible, quality improvement projects will utilize data andmeasures that are statistically valid, reliable and comparable over time. For eachproject, the QMC will:

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    Develop quantifiable measures; Measure the current level of performance (i.e. establish a baseline); Establish goals for quality improvement; Design and implement strategies to improve performance; and Establish projected timeframes for quality improvement and the frequency of

    periodic measures of progress in meeting goals.

    11.4 Key Service Indicators

    A component of the QMP is the tracking of key indicators of service quality. Theindicators will be function-specific, that is, different sets of indicators will be usedfor care and case management, clinical quality, accessibility and availability ofservices, credentialing, etc.

    Among the types of indicators that may be tracked and evaluated are:

    Member, group and provider complaints; Adverse clinical events and clinical quality flags; Telephone reports (tracking speed of answer, abandonment, blocked calls,

    etc.); Customer and provider satisfaction surveys; GeoAccess reports indicating number and geographic distribution of network

    providers; Customer service inquiries regarding availability of network providers; Credentialing turnaround time reports; Clinical appeals outcomes and timeliness reports; Inter-rater reliability and case audit reports; and Privacy violations.

    Tracking and reporting of service quality indicators are used by the QMC toidentify issues requiring immediate intervention, ensure adequate levels of serviceand quality are maintained, and identify possible quality improvement projects.

    11.5 Medical Advisory Committees

    Mountain State has established two Medical Advisory Committees (MACs),one which meets in the northern part of the state (Weirton) and one in the south-central part of the state (Charleston). The voting members of the MACs arenetwork physicians in private practice representing specialties (including bothprimary and specialty care) commonly utilized by Mountain State members. TheMACs are chaired by a Mountain State medical director.

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    A list of current MAC members is published on the Mountain State website, Please select the Provider tab at the top of the home page.

    The primary roles of the MACs are to: (1) review individual cases posing qualityof care or availability/accessibility of care issues; and (2) provide input onMountain State clinically-related policies, programs and initiatives. Thesepolicies and programs include, but are not limited to:

    Medical policies; MAC policies and procedures; Disease management programs; Clinical review criteria; Adult and pediatric preventive health guidelines; Access and availability standards; Patient safety initiatives; and QMP.

    Administrative support for the MACs is provided by the Office of NetworkCredentialing and Clinical Quality Improvement. You may directcommunications to or regarding the MACs to:

    Office of Network Credentialing and Clinical Quality ImprovementMountain State Blue Cross Blue Shield

    P.O. Box 1353Charleston, WV 25325

    11.6 Complaints About Quality or Accessibility of Care

    11.6.1 Referral

    Mountain State follows an established process to investigate and respond tocomplaints and concerns regarding the clinical quality of care oravailability/accessibility of healthcare services furnished to members by networkproviders.

    Such complaints are referred internally to the Office of Network Credentialingand Clinical Quality Improvement. In addition to external complaints, clinicalquality or availability/accessibility issues may be identified by internal processingor review of individual cases by other areas of the company (e.g. utilizationmanagement, case management, claims, customer services). Such issues are alsoreferred to the Office of Network Credentialing and Clinical QualityImprovement. Finally, clinical quality issues may be identified through internaltracking and review mechanisms (e.g. reports of mortalities involving planmembers).

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    A provider may refer a complaint, concern or question about the clinical qualityof care or availability/accessibility of services furnished to a Mountain State orFreedomBlue member by contacting:

    Office of Network Credentialing and Clinical Quality ImprovementMountain State Blue Cross Blue Shield

    P.O. Box 1353Charleston, WV 25325

    11.6.2 Investigation

    When a complaint or concern is received, a clinical quality improvement (QI)nurse will conduct a preliminary investigation. As part of such investigation, theQI nurse may request medical records and other information from the networkprovider(s) involved and the patient.

    Such requests generally are made in writing and a written response from theprovider is required. This is to ensure that all actions relating to investigation ofquality issues, including Mountain States requests and the providers responses,are thoroughly documented, and that all such documentation may be provided tomedical directors, the MACs, the Credentials Committees and/or external clinicalconsultants, as needed.

    Each case is reviewed with a Mountain State medical director. If the medicaldirector determines that the case indicates possible substandard care or actions bya network provider inconsistent with the providers obligations to make careavailable and accessible to plan members, then the medical director will refer thecase to one of the Mountain State MACs.

    11.6.3 MAC Review

    Mountain State operates two MACs through which it obtains involvement andinput from network physicians in review primarily of clinically-related programsand clinical quality issues. A more detailed overview of the MACs is provided inSection 11.5 of this Provider Manual.

    The voting members of the MACs are network physicians of various specialtiescommonly utilized by Mountain State members. When a clinical qualitycomplaint or issue is referred to the MAC, it is evaluated and discussed by theMAC members and the Mountain State medical director who chairs the MAC.The medical records and any communication with the provider(s) and patient areprovided to the MAC in advance of its review. This peer review process enablesobjective and thorough evaluation of whether care provided in an individual casemeets recognized standards of care and practice.

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    The MAC may direct the medical director to: (1) request additional clinicalinformation from the provider (e.g. if it does not appear in the medical recordspreviously obtained); and/or (2) request that the provider explain why he or shetook or did not take specific actions relating to the members care. All suchcommunications and responses are in writing.

    After the MAC has received all requested information, it will make adetermination of whether or not the quality of care furnished in the case meetsacceptable standards. If the MAC determines that the quality of care wasinadequate, it may direct that one or more actions be taken. These include, but arenot limited to:

    Sending a letter to the provider to educate him/her on the appropriate standardof care;

    Directing the Credentials Committee to monitor the providers future claimsand to identify any additional cases that may raise quality of care concerns;

    Directing the Credentials Committee to place the provider on an acceleratedre-credentialing cycle (e.g. one year) ; or

    Referring the case to the Credentials Committee to determine whethercorrective action (including restriction of clinical privileges, suspension ortermination from the Mountain State networks) is warranted.

    11.7 Provider Responsibilities

    It is the network providers responsibility to cooperate with all requests forinformation and assistance related to the Mountain State QMP. This basicobligation is reflected in the Mountain State provider agreements, credentialingpolicies and this Provider Manual. The providers cooperation is fundamental toMountain States efforts to promote quality care and availability/accessibility ofservices to members, and to ensure efficient and effective operation of MountainStates administrative operations.

    Failure of a provider to respond timely to requests for information may result incorrective action for administrative non-compliance by the Mountain StateCredentials Committee. Such action may include suspension or termination fromMountain States provider networks.

    11.8 Peer Review Protections

    Activities of the Mountain State Quality Management Program, includingactivities of the staff, medical directors, MACs and Credentials Committees, areafforded protections as peer review activities under state and federal law. Suchprotected activities include:

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    Evaluating and improving the quality of healthcare rendered; Reducing morbidity or mortality; Evaluation by healthcare professionals of the quality and efficiency of

    services ordered or performed by other healthcare professionals (includinginpatient hospital and extended care facility utilization review and ambulatorycare review); and

    Actions or recommendations of a professional review body, based on thecompetence or professional conduct of a physician which could adverselyaffect the health or welfare of a patient, and which could affect the clinicalprivileges or plan membership of the physician.

    Under West Virginia law (W.Va. Code 30-3C-1 et seq.), the proceedings andrecords of a peer review organization are confidential, privileged, are not subjectto subpoena or discovery proceedings and are not to be admitted as evidence inany civil action arising out of the matters which are subject to evaluation andreview.

    Accordingly, network providers and other peer review bodies (such as hospitalquality review committees) may furnish information requested by the MountainState QMP and know that the confidentiality of such information will bemaintained and protected.


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