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Chapter 10: Quality Management (QM) Program and Compliance Information

UnitedHealthcare Community Plan’s comprehensive Quality Improvement program falls under the leadership of the CEO and the chief medical officer. A copy of our Quality Improvement program is available upon request.

The program consists of:

  • Identifying the scope of care and services given
  • Developing clinical guidelines and service standards
  • Monitoring and assessing the quality and appropriateness of services given to our members based on the guidelines
  • Promoting wellness and preventive health, as well as chronic condition self-management
  • Maintaining a network of providers that meets adequacy standards
  • Striving for improvement of member health care and services
  • Monitoring and enhance patient safety
  • Tracking member and provider satisfaction and take actions as appropriate

As a participating care provider, you may offer input through representation on our Quality Improvement Committees and your provider services representative/ provider advocate.

We require your cooperation and compliance to:

  • Provide requested timely medical records.
  • Cooperate with quality-of-care investigations. For example, responding to questions and/or completing quality-improvement action plans.
  • Participate in quality audits, such as site visits and medical record standards reviews, and taking part in the annual Healthcare Effectiveness Data and Information Set (HEDIS®) record review.
  • Provide requested medical records for quality activities at no cost (or as indicated in your Agreement with us). You may provide records during site visits or by email, secure email or secure fax.
  • Respond timely to practitioner appointment access and availability surveys.
  • Allow the plan to use your performance data.
  • Offer Medicaid members the same number of office hours as commercial members (or don’t restrict office hours you offer Medicaid members.)

Cooperation with Quality-Improvement Activities

  • You must comply with all quality-improvement activities. These include:
  • Providing requested timely medical records.
  • Cooperating with quality-of-care investigations. For example, responding to questions and/or completing quality-improvement action plans.
  • Participating in quality audits, such as site visits and medical record standards reviews, and taking part in the annual Healthcare Effectiveness Data and Information Set (HEDIS®) record review.
  • Providing requested medical records at no cost (or as indicated in your Agreement with us). You may provide records during site visits or by email, secure email or secure fax.
  • Completing practitioner appointment access and availability surveys.

UnitedHealthcare Community Plan’s comprehensive Quality Improvement program falls under the leadership of the CEO and the chief medical officer. A copy of our Quality Improvement program is available upon request.

As a participating care provider, you may offer input through representation on our Quality Improvement Committees and your provider services representative/ provider advocate. We require your cooperation and compliance to:

  • Allow the plan to use your performance data.
  • Offer Medicaid members the same number of office hours as commercial members (or don’t restrict office hours you offer Medicaid members.)

Every year, UnitedHealthcare Community Plan conducts care provider satisfaction assessments as part of our quality improvement efforts. We assess and promote your satisfaction through:

  • Annual care provider satisfaction surveys.
  • Regular visits.
  • Town hall meetings.

Objectivity is our chief concern with the surveys’ objectivity. That’s why UnitedHealthcare Community Plan engages independent market research firm Center for the Study of Services (CSS) to analyze and report findings.

Survey results are reported to our Quality Management Committee. It compares the results year over year as well as to other UnitedHealthcare Community Plan plans across the country. The survey results include key strengths and improvement areas. Additionally, we carry out improvement plans as needed.

UnitedHealthcare Community Plan credentials and re- credentials you according to applicable Hawaii statutes and the National Committee of Quality Assurance (NCQA). The following items are required to begin the credentialing process:

  • A completed credentialing application, including Attestation Statement
  • Current medical license
  • Current Drug Enforcement Administration (DEA) certificate
  • Current professional liability insurance

We verify information from primary sources regarding licensure, education and training. We also verify board certification and malpractice claims history.

UnitedHealthcare Community Plan’s credentialing and recredentialing process determines whether you are a good fit for the UnitedHealthcare Community Plan care provider network. You must go through the credentialing and recredentialing process before you may treat our members.

Credentialing and Re-Credentialing activities are delegated to MDX Hawaii for all providers except for Behavioral Health providers and Home and Community Based providers (ie: Community Care Adult Foster Home, Adult day, Adult Health, Respite, chore services etc.)

Care Providers Subject to Credentialing and Recredentialing

UnitedHealthcare Community Plan evaluates the following practitioners:

  • MDs (Doctors of Medicine)
  • DOs (Doctors of Osteopathy)
  • DDSs (Doctors of Dental Surgery)
  • DMDs (Doctors of Dental Medicine)
  • DPMs (Doctors of Podiatric Surgery)
  • DCs (Doctors of Chiropractic)
  • CNMs (Certified Nurse Midwives)
  • CRNPs (Certified Nurse Practitioners)
  • Behavioral Health Clinicians (Psychologists, Clinical Social Workers, Masters Prepared Therapists)

Excluded from this process are practitioners who:

  • Practice only in an inpatient setting,
  • Hospitalists employed only by the facility; and/or
  • Nurse practitioners and physician assistants who practice under a credentialed UnitedHealthcare Community Plan care provider.

UnitedHealthcare Community Plan does not make credentialing and recredentialing decisions based on race, ethnic/ national identity, gender, age, sexual orientation or the type of procedure or patient in which the practitioner specializes.

Advance Directives

As part of re-credentialing, we may audit records of primary care providers, hospitals, home health agencies, personal care providers and hospices. This process helps us determine whether you are following policies and procedures related to advance directives. These policies include:

  • Respecting members’ advance directives, and placing them prominently in medical records.
  • Adhering to charting standards that reflect the member’s advance directives.

Credentialing Process

A peer review committee reviews all credentialing applications and makes a final decision. The decisions may not be appealed if they relate to mandatory criteria at the time of credentialing. We will notify you of the decision in writing within 60 calendar days of the review.

Recredentialing Process

UnitedHealthcare Community Plan recredentials practitioners every three years. This process helps assure you update time-limited documentation and identify legal and health status changes. We also verify that you follow UnitedHealthcare Community Plan’s guidelines, processes and care provider performance standards. You are notified before your next credentialing cycle to complete your application with MDX Hawaii Inc. Not responding to our request for recredentialing information results in administrative termination of privileges as a UnitedHealthcare Community Plan care provider. You have three chances to answer the request before your participation privileges are terminated.

Performance Review

As part of the recredentialing process, UnitedHealthcare Community Plan looks in its Quality Management database for information about your performance. This includes member complaints and quality of care issues.

Applicant Rights And Notification

You have the right to review information you submitted to support your credentialing/recredentialing application. This excludes personal or professional references or peer review protected information. You have the right to correct erroneous information you find. You may call to correct your information at any time. If erroneous information is found, a representative will contact you by fax or in writing. You must submit corrections within 30 days of notification by phone, fax or in writing. You also have the right to receive the status of your credentialing or recredentialing application by calling us.

Confidentiality

All credentialing information collected during the review process is kept confidential. It is only shared with your approval or as required by law with those involved in the credentialing process.

Failure To Meet Recredentialing Requirements

If you don’t meet our recredentialing requirements, we will end your participation with our network. We will give you a written termination notice. The termination notice will include the reasoning, the effective date and an explanation of your appeal rights, if applicable.

Contract Concerns

If you have a concern about your Agreement with us, send a letter to:

UnitedHealthcare Community Plan Central Escalation Unit
P.O. Box 5032
Kingston, NY, 12402-5032

A representative will work to resolve the issue with you. If you disagree with the outcome of this discussion, please follow the dispute resolution provisions of your Provider Agreement.

If your concern is about a UnitedHealthcare Community Plan procedure, such as the credentialing or Care Coordination process, we will resolve it by following the procedures in that plan. If you are still dissatisfied, please follow the dispute resolution provisions in your Provider Agreement.

If we have a concern about our Agreement with you, we will send you a letter. If the issue can’t be resolved this way, please follow the dispute resolution provisions in your Provider Agreement.

If a member has authorized you to appeal a clinical or coverage determination on their behalf, that appeal follows the member appeals process as outlined in the Member Handbook and this manual.

Health Insurance Portability And Accountability Act

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 aims to improve the efficiency and effectiveness of the United States health care system. While the Act’s core goals were to maintain insurance coverage for workers and fight health care fraud and abuse, its Administrative Simplification provisions have had the greatest impact on how the health care industry works. UnitedHealthcare Community Plan is a “covered entity” under these regulations. So are all health care providers who conduct business electronically.

Transactions And Code Sets

If you conduct business electronically, submit claims using the standard formats adopted under HIPAA. Otherwise, submit claims using a Clearinghouse.

Unique Identifier

HIPAA also requires unique identifiers for employers, health care providers, health plans and individuals for use in standard transactions.

National Provider Identifier (NPI)

The National Provider Identifier (NPI) is your standard unique identifier. It is a 10-digit number with no embedded intelligence that covered entities must accept and use in standard transactions. While HIPAA only requires you to use the NPI in electronic transactions, many state agencies require it on fee-for-service claims and on encounter submissions. For this reason, UnitedHealthcare Community Plan requires the NPI on paper transactions.

The NPI number is issued by the National Plan and Provider Enumeration System (NPPES). Share it with all affected trading partners, such as care providers to whom you refer patients, billing companies and UnitedHealthcare Community Plan.

Privacy Of Individually Identifiable Health Information

The privacy regulations limit how health plans, pharmacies, hospitals and other covered entities can use members’ medical information. The regulations protect medical records and other identifiable health information. This includes electronic, paper or spoken data.

They enhance consumers’ rights by giving them access to their health information and controlling its inappropriate use. They also improve health care delivery by extending the privacy efforts of states and health systems to a national level.

Security

Covered entities must meet basic security measures:

  • Help ensure the confidentiality, integrity and availability of all electronic protected health information (PHI) the covered entity creates,
  • Protect against any reasonably anticipated threats, uses or disclosures of information not permitted or required under the Privacy Regulations, and
  • Help ensure compliance with the security regulations by the covered entity’s staff.

UnitedHealthcare Community Plan expects you to comply with all HIPAA regulations.

Find additional information on HIPAA regulations at cms.hhs.gov.

Introduction

UnitedHealthcare Community Plan is dedicated to conducting business honestly and ethically with you, members, suppliers and government officials and agencies. Making sound decisions as we interact with you, other health care providers, regulators and others is necessary for our continued success and that of our business associates. It’s also the right thing to do.

Compliance Program

As a segment of UnitedHealth Group, UnitedHealthcare Community Plan is governed by the UnitedHealth Group Ethics and Integrity program. The UnitedHealthcare Community Plan Compliance program incorporates the required seven elements of a compliance program as outlined by the U.S. Sentencing Guidelines:

  • Oversight of the Ethics and Integrity program.
  • Development and implementation of ethical standards and business conduct policies.
  • Creating awareness of the standards and policies by educating employees.
  • Assessing compliance by monitoring and auditing.
  • Responding to allegations of violations.
  • Enforcing policies and disciplining confirmed misconduct or serious neglect of duty.
  • Reporting mechanisms for workers to alert management and/or the Ethics and Integrity program staff to violations of law, regulations, policies and procedures, or contractual obligations.

UnitedHealthcare Community Plan has compliance officers for each health plan. In addition, each health plan has a compliance committee consisting of senior managers from key organizational areas. The committee provides program direction and oversight.

Reporting and Auditing

Report any unethical, unlawful or inappropriate activity by a UnitedHealthcare Community Plan employee to a UnitedHealthcare Community Plan senior manager or directly to the Compliance Office.

UnitedHealthcare Community Plan’s Special Investigations Unit (SIU) is an important part of the Compliance program. The SIU focuses on prevention, detection and investigation of potentially fraudulent and abusive acts committed by care providers and members. This department oversees coordination of anti-fraud activities.

To facilitate the reporting process of questionable incidents involving members or care providers, call our Fraud and Abuse line.

Please refer to the Fraud, Waste and Abuse section of this manual for additional details about the UnitedHealthcare Community Plan Fraud, Waste and Abuse program.

An important aspect of the Compliance program is assessing high-risk areas of UnitedHealthcare Community Plan operations and implementing reviews to help ensure compliance with law, regulations and policies/contracts. When informed of potentially inappropriate or fraudulent practices within the plan or by you, UnitedHealthcare Community Plan will conduct an investigation. You must cooperate with the company and government authorities. This means giving access to pertinent records (as required by your applicable Provider Agreement and this manual) as well as access to office staff. If we establish activity in violation of law or regulation, we will advise appropriate governmental authorities.

If you become the subject of a government inquiry or investigation, or a government agency requests documents relating to your operations (other than a routine request for documentation), you must provide UnitedHealthcare Community Plan with the details. You must also reveal what triggered the inquiry.

Extrapolation Audits of Corporate-Wide Billing

UnitedHealthcare Community Plan will work with the State of Hawaii to perform “individual and corporate extrapolation audits.” This may affect all programs supported by dual funds (state and federal funding) as well as state-funded programs, as requested by the Hawaii Department of Health and Human Services.

Record Retention, Reviews and Audits

You must maintain an adequate record-keeping system for recording services, charges, dates and all other commonly accepted information for services rendered to our members. Records must be kept for at least 10 years from the close of the Hawaii program agreement between the state and UnitedHealthcare Community Plan or another period as required by law. If records are under review, they must be retained until the audit is complete. UnitedHealthcare Community Plan and its affiliated entities (including OptumHealth) will request and obtain prior approval from you for the records under review or inspection. You agree to refund the state any overpayment disclosed by any such audit.

If any litigation, claim, negotiation, audit or other action involving the records has been started before the 10-year period ends, you agree to keep the records until one year after the resolution of all issues that come from it. The state may also perform financial, performance and other special audits on such records during business hours throughout your Provider Agreement.

To help ensure members receive quality services, you must also comply with requests for on-site reviews conducted by the state. During these reviews, the state will address your capability to meet Hawaii program standards.

You must cooperate with the state or any of its authorized representatives, the Hawaii Department of Health and Human Services, the Centers for Medicare & Medicaid Services, the Office of Inspector General, or any other agency prior-approved by the state, at any time during your Provider Agreement.

These entities may, at all reasonable times, enter your premises. You agree to allow access to and the right to audit, monitor and examine any relevant books, documents, papers and records to otherwise evaluate (including periodic information systems testing) your performance and charges.

We will perform reviews and audits without delaying your work. If you refuse to allow access, this will constitute a breach of your Provider Agreement.

Delegating and Subcontracting

If you delegate or subcontract any function, the delegate or subcontractor must include all requirements of your applicable Provider Agreement and this manual.

UnitedHealthcare Community Plan and affiliates monitor complaints for quality of services (QOS) concerning participating care providers and facilities. Complaints about you or your site are recorded and investigated. We conduct appropriate follow-up to assure that members receive care in a safe, clean and accessible environment. For this reason, UnitedHealthcare Community Plan has set Clinical Site Standards for all primary care provider office sites to help ensure facility quality.

UnitedHealthcare Community Plan requires you and your facilities meet the following site standards:

  • Clean and orderly overall appearance.
  • Available handicapped parking.
  • Handicapped accessible facility.
  • Available adequate waiting room space.
  • Adequate exam room(s) for providing member care.
  • Privacy in exam room(s).
  • Clearly marked exits.
  • Accessible fire extinguishers.
  • Post file inspection record in the last year.

Criteria for Site Visits

The following table outlines the criteria used to require a site visit. When the threshold is met, we conduct a site visit according to UnitedHealthcare Community Plan policy.

QOS Issue:
Issue may pose a substantive threat to patient’s safety

Criteria:

  • Access to facility in poor repair to pose a potential risk to patients
  • Needles and other sharps exposed and accessible to patients
  • Drug stocks accessible to patients
  • Other issues determines to pose a risk to patient safety

Threshold:

One complaint

QOS Issue:

Issues with physical appearance, physical accessibility and adequacy of waiting and examination room space

Criteria:

  • Access to facility in poor repair to pose a potential risk to patients
  • Needles and other sharps exposed and accessible to patients
  • Drug stocks accessible to patients
  • Other issues determines to pose a risk to patient safety

Threshold:

Two complaints in six months

QOS Issue:
Other

Criteria:

All other complaints concerning the office facilities

Threshold:

Three complaints in six months