October Quality Topic
Quality and Compliance
Training
Chapter I:
State Requirements
The different types of state specific laws include:
IRO requirements UM licensure
CM licensure
Prompt pay requirements Clean claims laws
Security & privacy statutes
State Regulatory Requirements
• Although HealthSmart Care Management Solutions is based out of Texas, we must comply with all Federal and State requirements for the groups we serve based on their location.
• HealthSmart CMS is currently licensed to provide UM services in all states that have requirements except Rhode Island.
State Compliance Log
• We currently have a database on the shared drive that contains all state statutory requirements that we follow.
• This spreadsheet includes any updates for new state, federal, and HIPAA statutes.
• Our compliance team is currently in the process of updating this compliance spreadsheet with new PPACA regulations.
• The existing compliance log is being audited and updated with new PPACA regulations and will be available on Sharepoint as soon as the audit is
Chapter II:
Compliance Measures
HealthSmart Promotes Compliance by Looking at 3 Types of Measures: 1. Structural Measures – codes of conduct and other written standards are in
place (ex – written P&Ps).
2. Process Measures – Monitors the extent to which the standards are followed by all employees. (ex – do we follow written P&P in day to day activities).
3. Outcomes Measures – compares actual performance on identified standards with industry benchmarks
HealthSmart Outcome Measurements
• Abandonment Rates and Other Phone Stats
• Complaint Trends
• Appeal Results and Timeframes
• Readmissions within 30 days (7 days for new clinical study)
• UM Stats (bed days/1000, admits/1000, LOS)
• Interrator Reports
How to Report Compliance Violations
• Report it directly to your supervisor• Report it anonymously:
Submit the violation to our Compliance Office, Melissa Nollkamper
You may submit it by interoffice mail to the Irving Office
(Attn: Melissa Nollkamper)
Contact her by phone or email:
Phone Number: (214) 574-2370
Email Address: [email protected]
Call the Compliance Hotline and leave an anonymous message about
suspicious issues.
Remember…
• The HealthSmart Care Management Compliance program and training are designed to help diminish errors, incidences, and/or non-compliance in the workplace.
• By identifying these areas of improvement and developing plans of action, HSCM will continue to maintain the highest levels of quality on all products and services offered.
Chapter III:
Defining Fraud and Abuse in Healthcare
• Healthcare fraud and abuse is committed when false or misleadinginformation is intentionally submitted for use in determining the amount of healthcare benefits payable
• Healthcare fraud can be committed by anyone, such as dishonest healthcare providers or by the plan members themselves.
Healthcare Fraud
Examples of Healthcare Fraud that we Monitor: • Billing for services not actually performed
• Falsifying a patient’s diagnosis / procedures performed to justify surgeries that are not needed or to obtain payment for non-covered surgeries
• Forging or altering bills or receipts
• Using another patients medical card to obtain services for a non-covered patient
Suspected Fraud & Abuse
Our Responsibilities for Suspected Fraud & Abuse Activity: • Ask numerous questions about services rendered to patients • Monitor claims to match service to appropriate diagnosis or
frequency of service
• Educate Patients on disclosing insurance information • Report suspected fraud or abuse cases to your supervisor
Chapter IV:
Quality and Quality Management
Quality Is…
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
Quality Management Is…
Creating and implementing an architecture that motivates, supports, and enables quality in all the activities of the organization
The 6 Aims of Quality
Quality Healthcare should be…
1. Safe
Avoid injuries to patients from care that is intended to help them 2. Effective
Provide services based on scientific knowledge to patients that will
benefit from the service; refrain from providing services to those unlikely to benefit (i.e. avoid underuse and overuse, respectively)
3. Patient-centered
Provide care that is respectful and responsive to individual patient
preferences, needs, and values; ensure that patient values guide all clinical decisions
The 6 Aims of Quality
(continued) 4. TimelyReduce waits and potentially harmful delays for both those who receive and those who give care
5. Efficient
Avoid waste of equipment, supplies, ideas, and energy 6. Equitable
Provide care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geography, or socioeconomic status
Communicating Quality
• Quality issues can arise at every level in the organization
• It is essential that proper communication flows are established to address issues that can impact quality
• Each employee has the potential to positively or negatively impact both
customer service and service delivery by how they address and report quality issues
HealthSmart Care Management
Quality Communication Flow
Staff Member
Departmental Meetings
Internal Quality Committee (CQI)Medical Advisory Committee
Measuring Quality
• Statistically valid techniques are utilized • Must be quantifiable
• Must be measurable to showcase quality improvement, or be comparable over time
• Examples include:
Phone stats (such as call wait time and abandonment rate) Monthly Audits/Interrator Reports and Case Reviews Length of Stay and Readmission reviews
Quality Focus on Patient Safety
• Patient Safety
Freedom from accidental or preventable injury produced by medical care
What HealthSmart Care Management is doing:
Quality Improvement Projects (QIP)
Call backs to member after any inpatient admission
– Rx filled, appointment follow up made, understand DC instruction
Review inpatient for quality of care
– Review of Never-Event (Adverse Event)
– Review of Case Management
• Adverse Event (Never-Event)
Injury caused by medical management rather than the underlying disease or condition of the patient
Falls
Decubitus (bed sores)
Nosocomial infections (infections acquired in the hospital) Wrong medication, wrong surgery, wrong patient
Remember…
• We are in the position to identify errors that are potentially preventable by tracking and reporting information or by directly interacting with
facilities or providers.
• As a HealthSmart Care Management Team, we all need to do our part every day to ensure the upmost quality service for our HealthSmart members!
Take Your Completion Survey!
Please click on the link below to complete the October Quality Topic completion survey. The answers to the quiz questions can be found in this presentation.
ALL Care Management staff is responsible for submitting
their online completion survey by October 31st.
Completion Survey Link:
https://www.surveymonkey.com/s/Oct2014QualityTopicSurvey
Please contact Joslyn Crain if you have any questions.
