Structure of the QI Program
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Inclusion of Participating Providers in the QI Program
Quality Program Organizational Structure
The Quality Improvement Program of the Healthier New Jersey Insurance Company d/b/a Braven Health is a coordinated and comprehensive program with the goal to optimize the health status of the Company’s members by promoting improvements in health care delivery and customer service intended to yield meaningful outcomes in health status and satisfaction.
The Company’s Board of Directors (“Braven Health Board”) holds the final authority and accountability for the Quality Improvement Program (the “Program”). The Braven Health Board has delegated the oversight of the Program to the Braven Health Quality Committee, a subcommittee of the Braven Health Board. Braven Health has engaged Horizon BCBSNJ to operate the Braven QI Program with a Quality Improvement Committee (“QIC”) regularly reporting to the Quality Committee.
The responsibilities, basic structure and operation of the Quality Committee is outlined in its committee charter. The Committee shall annually review this charter and recommend any changes to the Braven Health Board for approval. Braven Health procures the staff and other services from Horizon Healthcare Services, an experienced and accredited operator of Medicare Advantage health plans to operate its Quality Management Program.
The Braven Health Board retains ultimate responsibility for the oversight of the Program, and reviews and approves reports of the Braven Health Quality Committee. The Braven Quality Committee will draft and present for approval the Quality Improvement Program Description, Work Plan and Evaluation annually. The QIC provides reports to the Braven Quality Committee on a timely basis monitoring performance of the QI Program, status of the work plan and analyses necessary to evaluate the QI Program. Braven Health is a coordinated and comprehensive program whose goal is to optimize the health status of its members by creating quality differentiators aimed at delivering meaningful outcomes. As a result, Braven Health may choose to delegate services to entities outside of Horizon as needed. The oversight of these delegated agreements are facilitated directly by Braven Health.
Committee Structure: There shall be five (5) members of the Quality Committee, including the chair. Each Committee member shall serve until the next annual meeting of the Healthier New Jersey Insurance Company (dba Braven Health) Board. Any vacancies shall be filled by a majority vote of the Healthier New Jersey Insurance Company Health Board. The committee members shall consist of the key individuals, identified by the Healthier New Jersey Insurance Company.
The organizational structure of Braven Health Quality committee supports the implementation of the QI Program by engaging the Horizon Healthcare Services Quality Improvement Committee and its subcommittees. Each subcommittee has a charter that outlines its purpose, scope, meeting frequency, and composition. Below are descriptions of the Quality Improvement Committee and subcommittees that report to the QIC.
QUALITY IMPROVEMENT COMMITTEE (QIC)
The QIC’s purpose is to oversee all Braven Health QI activities. The QIC is a multidisciplinary committee that meets on a regular basis, at least 6 times per year. This frequency is sufficient to demonstrate that the committee is following up on all findings and required actions. The role, structure, and function of the committee are specified in its charter. Annually, the charter is revised as needed and approved by the committee. Recorded meeting minutes document the committee's activities, findings, recommendations and actions.
The QIC is accountable to the Braven Health Quality Committee. On a Quarterly basis, the activities, findings, recommendations and actions of the QIC are reported to the Quality Committee. There is active participation on the QIC from network providers. At least one participating provider attends all QIC meetings.
Delegated Vendor Oversight Committee (DVOC)
The DVOC is an interdisciplinary subcommittee that provides oversight of delegated vendors performing services as Horizon BCBSNJ’s resource in operating the Braven Health Quality Program related to healthcare delivery and customer service. The committee meets at least eight times per year.
Stars Steering Subcommittee
The Stars Rating Program Steering Subcommittee is an interdisciplinary committee that meets at least 6 times per year and oversees efforts intended to improve the quality and customer experience of the care and services Braven Health provides to its Medicare beneficiaries. The subcommittee coordinates efforts that focus on improving the plan’s performance as measured by Medicare Star Rating and CAHPS scores. The subcommittee also provides oversight of efforts aimed at improving the quality and cost effectiveness of the care and services Braven Health provides to all members. The subcommittee also coordinates efforts focused on improving the plan’s Medicare and HEDIS performance.
The HEDIS Workgroup is an interdisciplinary team with representation from the Quality, Case Management, Utilization Management, Behavioral Health, Pharmacy, Delegate and Vendor Oversight Departments. The workgroup provides oversight of efforts aimed at improving the quality and cost effectiveness of the care and services provided to all members. The workgroup coordinates efforts focused on improving the plan’s HEDIS performance. This workgroup meets four times per year.
Utilization Management/Case Management Committee (UM/CM)
The purpose of the UM/CM committee is to ensure high quality, cost-effective health care for all Braven Health members. The committee is responsible for reviewing the management of Medicare health services to support Braven Health’s vision of improving quality and enhancing the member experience. The UM/CM Committee meets at least five times per year. This committee includes active involvement from external physicians.
Administrative Policy Approval (APA) Subcommittee
The APA Subcommittee meets monthly, and the purpose of the committee is to review and approve all Braven Health Administrative Policies and Procedures.
Quality Peer Review Committee (QPRC)
The goal of the QPRC is to ensure members receive quality health care and excellent service. QPRC meets at least six times per year and on an ad hoc basis to review potential quality of care and service issues involving Braven Health members. The QPRC includes participation from external physicians.
Member Services Satisfaction Committee (MSSC)
The MSSC is a multidisciplinary committee, focusing on issues related to member satisfaction in order to create proactive action plans to address the identified barriers to providing Braven Health members with the highest quality experience. The MSSC reviews reports focused on call center performance, member grievances, and claims as well as appeals associated with these issues. The MSSC reviews CAHPS results and other member satisfaction survey results so that the committee can coordinate interventions aimed at improving member experience. The committee also determines areas of service with the greatest effect on member satisfaction, and identifies areas of opportunity to increase quality of care through quality initiatives. This committee meets at least four times per year.
Provider Service Satisfaction Committee (PSSC)
The purpose of the PSSC is to oversee and ensure provider satisfaction with Braven Health. The PSSC reviews grievance and appeal data and specific issues related to provider satisfaction. The committee meets on a quarterly basis.
The Credentials Committee is a committee within the Horizon BCBSNJ Quality Improvement Committee (QIC), established to implement and oversee credentialing, re-credentialing, certification, and/or re-certification of physicians, health care professionals, facilities and ancillary providers. The Credentials Committee is empowered by Horizon Healthcare Services, Board of Directors, acting on Braven Health’s behalf, and the QIC with decision-making authority on matters pertaining to provider credentialing and re-credentialing. This committee meets monthly.
Pharmacy and Therapeutics (P&T) Committee (Medicare)
The Medicare P&T Committee is responsible for clinical support of the Medicare Pharmacy Program. The P&T Committee is comprised of primary care and specialty physicians, pharmacists and other health care professionals. The Medicare P&T Committee provides input on pharmaceutical management procedures and on developing, managing, updating and administering the Medicare Formulary. The Medicare Formulary development and maintenance is delegated to the Pharmacy Benefit Manager, Prime Therapeutics, and is overseen by the Prime P&T Committee with active participation by the Horizon Healthcare Services Medicare Pharmacy Program acting as a delegated service provider to Braven Health. The Medicare P&T Committee meets at least quarterly.
Inclusion of Participating Providers in the QI Program
Participating providers are included as voting members of the QIC. Participating providers are also voting members of the Horizon Utilization Management/Case Management Committee, Pharmacy and Therapeutics Committees, and Quality Peer Review Committee. These Committees provide input to the Quality Program operated by Horizon BCBSNJ, which operates a Quality Program as a delegated service provider to Braven Health. Participating physicians and other providers remain informed about the written QI Program Description available via provider newsletters and the plan’s website at www.bravenhealth.com. Providers can also access information in the Provider Administrative Manual about how they can be included in the design, implementation, and review and follow up of Braven Health QI activities.
Quality Program Organizational Structure
Organizational Chart information is reserved for internal use only.
QI Program’s Resources
The Braven Health QI Program has the full support of Healthier New Jersey Insurance Company d/b/a Braven Health executive leadership. To demonstrate this support, all departments within the division collaborate and contribute to the success of the QI Program through their focus on quality in their daily activities and their participation in the QIC.
Braven Health has engaged Horizon to operate and staff the QI Program. The Program has sufficient material resources and staff with the necessary education, experience and/or training to effectively accomplish the QI Program’s activities. In addition, the Quality Management Department has access to consultants who provide activities such as statistical analysis, business process improvement recommendations, quality-related education and accreditation preparation support. To maintain and improve quality performance, the QI Program monitors all current and planned initiatives to assess current and future staffing needs. This opportunity ensures that the appropriate staff is in place to adequately address the needs of the quality improvement efforts. Below are descriptions of the key roles within Horizon that provides support to the Braven Health QI Program.
QI PROGRAMS STAFFING
Vice President and Chief Medical Officer (VP/CMO)
The VP & Chief Medical Officer of Horizon is a board-certified New Jersey licensed physician experienced in health insurance, managed care plan operations, NCQA accreditation and pharmacy benefit management. The VP/CMO is responsible for the adoption and implementation of the QI Program. The VP/CMO is an active participant in providing quarterly reports from the QIC, including the quality-related activities of Braven Health in 2023 to the Braven Health Board’s Quality Subcommittee. This reporting may be delegated to the medical director and/or quality director assigned to the Quality Management Department.
Executive Medical Directors
The Horizon executive medical directors provide senior level leadership and direction, and contribute to Quality Management initiatives. These initiatives include accreditation and CMS Star programs, as well as furnishing strategic and UM oversight for Braven Health. The executive medical directors establish and implement utilization standards, provide overall medical expertise to ensure continuous quality improvement, work to ensure that cost-effective services are provided to members, maintain effective provider relations and develop clinical innovations.
Senior Medical Directors/Medical Directors/Director of Clinical Behavioral Health
The Horizon Senior Medical Directors, Medical Directors and Director of Clinical Behavioral Health Services provide support to the QI Program and the Quality Management Department. They are involved in the evaluation of the clinical and service functions of Braven Health including (but not limited to) clinical practice guidelines, grievances, quality of care referrals, HEDIS/Stars/CAHPS/HOS initiatives and corrective action plans (CAPs).
Senior Director, Chief Quality Officer
The Senior Director, Chief Quality Officer, acting as Horizon’s resource in operating the Braven Health Quality Program, reports to the VP & Chief Medical Officer. The director has experience in Continuous Quality Improvement (CQI) methodology, state contractual requirements, and NCQA, DMAHS and CMS quality standards. The director has a master’s degree in business administration, with concentrations in management information systems and risk management. The director is responsible for design, development, and implementation of on-going improvement and maintenance of quality improvement initiatives necessary for attaining NCQA accreditation, and meeting CMS guidelines. The director provides leadership for implementing, monitoring and evaluating the Quality Improvement Program for Braven Health. The director also leads and directs processes and overall quality improvement activities that produce better patient care and more efficient operations. The director is also responsible for the oversight of the business areas within the Quality Management Department including HEDIS, Star Rating Program, pay for performance incentives and population health. The director represents the Quality Management Department on Horizon committees and serves as the Quality Management Medical Director’s co-chair.
Director of Quality Management Performance and Reporting Operations
The Director of Horizon Quality Management Performance and Reporting Operations acting as Horizon BCBSNJ’s resource in operating the Braven Health Quality Program performance reporting requirements and reports directly to the Senior Director, Chief Quality Officer. The director has a Bachelor of Arts (B.A.) and maintains expertise in HEDIS Reporting and Quality Data management across multiple products and programs. The director is responsible for strategic and tactical leadership for quality improvement and reporting across the organization as required by NCQA, DMAHS, CMS and reported through the Inovalon ONE® Platform. They also direct the design and implementation of quality health measure reporting and their associated activities required by NCQA, DMAHS and CMS, including HEDIS initiatives and related activities assigned for all Horizon Products.
Director, Quality Management Performance Improvement
Horizon’s director of Quality Management Performance Improvement reports to the Senior Director, Chief Quality Officer. The director has experience leading HEDIS performance improvement strategies and has extensive knowledge of NCQA, CMS and State regulatory requirements. The director develops and monitors performance improvement strategies for Horizon with specific goals for quality improvement. The director oversees member communication initiatives as it relates to HEDIS gap closure, which include member and provider education and monitoring the effectiveness of all campaigns. The director develops departmental reports and presents these reports to the leadership group directly and through the committee reporting structure.
Senior Director of Clinical Behavioral Health Services
The Senior Director of Horizon Clinical Behavioral Health Services acting as Horizon BCBSNJ’s resource in operating the Braven Health Quality Program reports directly to the Vice President of Behavioral Health. The director has a doctoral degree in social work and is a licensed clinical social worker. The director monitors the effectiveness of behavioral health care services including utilization management, behavioral health case management and all quality management activities related to behavioral health. Internal management of behavioral health services allows Braven Health to be in a stronger position to work directly with providers and health systems to improve integration of physical and behavioral health care for our members.
Quality Management Department Managers
Horizon Quality Management Department managers, acting as Horizon BCBSNJ’s resource in operating the Braven Health Quality Program, reports to the director within the Quality Management Department. The quality managers are comprised of nurses, social workers and non-clinicians with backgrounds in quality assurance, compliance, analytics and regulatory affairs. Managers are responsible for routine operations within their scope of accountability. Managers have specific business areas within the Quality Management Department that they oversee including member and provider grievances and appeals, quality peer review, audits, HEDIS/Star Rating performance, quality policy revisions, accreditation, quality assurance and quality related compliance.
Quality Management Department Supervisors
Supervisors within the Horizon Quality Management Department acting as Horizon BCBSNJ’s resource in operating the Braven Health Quality Program report to managers and/or directors. Quality Management Department supervisors include both clinicians (RNs and LPNs) and non-clinicians. The supervisors are responsible for ensuring that the Quality Management Department’s staff completes daily operations as outlined within policies and procedures.
QUALITY MANAGEMENT DEPARTMENT SUBJECT MATTER EXPERTS
Examples include, but are not limited to, the following.
The accreditation specialists support the Horizon Quality Management Department’s goal of improving the quality of health care for Braven Health members through ongoing monitoring of compliance with accreditation standards and regulatory requirements. The specialists work with all business areas, as well as with delegated vendors, to ensure that their work and reporting supports all applicable NCQA Health Plan Accreditation Standards.
Performance Improvement Project (PIP) Specialists
The Quality Department is responsible for the design, implementation, execution, analysis, and reporting of New Jersey Division of Medical Assistance & Health Services (DMAHS) and CMS required PIPs. The PIP specialists lead the Quality Management Department, as well as other Horizon departments and external collaborators acting as Horizon BCBSNJ’s resource in operating the Braven Health Quality Program, in the work required to successfully achieve the goals of each of QI project.
Health Data Analysts
Health data analysts perform research, analysis, programming, implementation and coordination to ensure accurate and timely reporting for the Quality Management Department acting as Horizon BCBSNJ’s resource in operating the Braven Health Quality Program. The responsibilities include, but are not limited to, analysis reporting, development of databases and reports that are responsive to department needs, review and coordination of all data requests to ensure data consistency and accuracy, utilization of various software packages to extract and analyze data, and support of all Health Services departments on data requirements for quality activities.
Quality Outreach Specialists
Quality Outreach Specialists are responsible for the coordination, implementation and monitoring of all Braven Health Medicare (Star Rating) HEDIS member and provider outreach, engagement and intervention. This position is also responsible for assisting the manager of Outreach & Interventions in operationalizing all initiatives to improve HEDIS performance by working with internal and external stakeholders.
Additionally, the QI Program pursues an integrated approach to achieving ongoing improvements in the quality of care and service delivered to members. Horizon staff in the Quality Department, acting as Horizon BCBSNJ’s resource in operating the Braven Health Quality Program, work closely with the following departments:
Network Contracting & Servicing works with Quality Management to ensure that the tools to assess the access and availability of practitioners and providers are adequate, that practitioners/providers comply with the QI Program, that clinical materials distributed to practitioners are easily understood and useful, and that practitioners understand members’ rights and responsibilities and treat enrolled members accordingly.
Clinical Services Operations includes Care, Case and Disease Management and UM. Care, Case and Disease Management staff identifies and refers potential quality issues to the Quality Management Department for investigation, recommends benefit enhancement, approves clinical practice guidelines and participates in the QIC.
Delegate Vendor Oversight (DVO) and Quality Management staff work collaboratively in the review of Quality Management initiatives with delegates and ensures compliance with the NCQA standards. In addition, DVO provides oversight of the activities and responsibilities of delegated vendors to ensure quality health care is provided to members.
External Quality Review
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
CMS evaluates the health plan based on a report called Organizational Determinations, Appeals and Grievances (ODAG) during a CMS Program Audit. These audits are random every 2-6 years where the health plan will have to demonstrate compliance within a specified timeframe of data, typically a lookback period of 3 months.
Additionally, there is a Part C and D Data Validation review by CMS in which is a review of the ODR (Organizational Determinations and Reconsiderations) and Grievances reports. This is a retrospective review of the previous year’s data. The purpose of this review is to ensure the data submitted was accurate and the process used in collecting the data is taking place per CMS standards. CMS benchmarks the health plan against other plans. Results are not shared as the CMS review is their monitoring tool.
CMS also reviews the plan’s timeliness by conducting an annual Timeliness Monitoring Project (TMP). They conduct a timeliness analysis on all Part C Appeals (pre-service and claims) and determine a rate of timeliness for each case type. The findings are provided to the health plan for review and may result in compliance actions, if necessary. The findings, may also have implications for the Star Ratings on two measures related to timeliness and accuracy of decision making.
In order to ensure audit readiness, regular and consistent monitoring of ODAG and ODR functions is performed. In addition, each department is responsible for maintaining workflows which reference regulatory requirements and are reviewed annually.
The Horizon Behavioral Health (BH) Program ensures the provision of quality behavioral health care for Braven Health members. Behavioral Health Case Management services are available to the Braven Health Medicare membership. Case managers provide assessment, development and implementation of individualized plans of care; and offer coordination of medical and behavioral health care services for members and their families. The Behavioral Health Program utilizes the Care Radius medical management system to support delivery and documentation of the case management process.
The Senior Director of Behavioral Health Services reports into QIC and a behavioral health practitioner participates on the QIC, UM/CM, and P&T Committees to provide information and guidance on mental health/substance use disorder topics and related quality initiatives and activities. Additionally, the Behavioral Health Network Management Department monitors network access and availability to ensure the adequacy of the behavioral health provider network. Deficiencies are acted on to reduce barriers to access and ensure continuity of care for members.