Monitoring of Network Care Providers and Health Care Professionals
We monitor sanction activity from state licensing boards, CMS, OIG and other regulatory bodies. If we find a care provider has a sanction that results in loss of license or material restriction, we terminate them from our network.
Care Provider Office Site Quality Review
We have office site standards that you must follow, including:
- Physical accessibility, such as handicapped accessible;
- Physical appearance of the site;
- Adequacy of waiting and examining room space;
- Availability of appointments; and
- Adequacy of treatment record keeping (e.g., secure/ confidential filing system).
We continually monitor member complaints relating to these standards against our established complaintthreshold. If we receive a member complaint within 60 days of the threshold being met, we conduct a full-assessment site visit.
We use a standardized site visit survey form that lists office- site and medical/treatment record-keeping standards.
Based on the results of the site visit, we start corrective action to improve those office sites that do not meet standards. We conduct a follow up visit to evaluate the effectiveness of those corrections within six months.
Should you fail to pass the revisit, we will continue to work with your office until the thresholds are met. We document each step of the process.