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Quality Management

The Quality Management Program consists of two major components: clinical and service activities. The range of clinical activities is extensive, encompassing preventive care, acute care, chronic care and care provided for special populations. It monitors member education and screening, provider credentialing, practice guidelines, medical record documentation, delegation and compliance. The service activities of the program monitors accessibility of care, member satisfaction and member complaints and appeals. Contract, regulatory requirements and accreditation standards determine the applicability of a specific program element.

The Quality Management Program further monitors the availability, accessibility, continuity and quality of care on an ongoing basis.

The Quality Management Program monitors the availability, accessibility, continuity and quality of care on an ongoing basis. Indicators of quality care used to evaluate the health care services provided by all participating health care professionals include:

  • A mechanism for monitoring patient appointments and triage procedures, discharge planning services, linkage between all modes and levels of care and appropriateness of specific diagnostic and therapeutic procedures, as selected by the Quality Improvement Committee;
  • A mechanism for evaluating all providers of care; and
  • A system to monitor physician and member access to utilization management services.

More specific program objectives include:

  • Specifying standards of care, criteria and procedures for the assessment of the quality of services provided and the adequacy and appropriateness of health care resources used.
  • Monitoring member satisfaction and participating network physicians’ response and feedback on plan operations.
  • Empowering members to actively participate in and take responsibility for their own health through the provision of education, counseling and access to quality health care professionals.
  • Maximizing safety and quality of health care delivered to members through the continuous quality improvement process.
  • Evaluating and maintaining a high-quality participating network through a formalized credentialing and recredentialing process.
  • Establishing long-term collaborative relationships with individuals and organizations committed to continuously improving the quality of care and services that they provide.
  • Maintaining effective communications systems with members and health care professionals to evaluate performance with respect to their needs and expectations.
  • Monitoring the utilization of medical resources using medical management processes as defined in the Utilization Management Program Description.
  • Maintaining a structured, ongoing oversight process for quality improvement functions performed by independently contracted entities and/or delegates.
  • Fulfilling the quality-related reporting requirements of applicable state and federal statutes and regulations, as well as standards developed by private outside review and accreditation agencies that Horizon BCBSNJ chooses to adhere to.

To receive a more detailed plan, please call the Quality Management Department at 1-877-841-9629.

MEDICAL RECORDS STANDARDS

In accordance with the CMS, the National Committee for Quality Assurance (NCQA) and URAC guidelines on standards for medical record documentation, Horizon BCBSNJ requires participating physicians and other health care professionals to adhere to the following commonly accepted practices regarding medical record documentation. The items below are also used in our medical record audits:

  • Medical Record Organization – Medical records will be organized and maintained in a systematic and consistent manner that allows easy retrieval.
  • Medical Record Availability – The physician has a process to make records available to covering health care professionals and others, as needed. Physician communicates to staff guidelines relative to the dispersal/retrieval of confidential patient medical records within and/or outside the office, such as in the case of a covering health care professional requesting medical records.
  • Medical Record Confidentiality – Access to medical records is limited to appropriate office staff:
    • All medical records are stored out of reach and view of unauthorized persons.
    • All electronic medical records are maintained in a system that is secure and not accessible by unauthorized persons.
    • Staff receives periodic training in member information confidentiality.
  • Dated Entries – Entries and updates to a medical record are dated with the applicable month, day and year.
  • Author Identification – Entries are initialed or signed by the author. Author identification may be a handwritten signature, unique electronic identifier, initials or any other unique identifier system the health care professional chooses.
  • Page Identification – Patient name or unique identifier is found on each page in the medical record.
  • Personal/Biographical Data – The medical record will contain patient personal/biographical information, such as:
    • Patient’s insurer.
    • Patient’s home address.
    • Patient’s home, work and/or cell phone number.
    • Emergency contact name and phone number.
  • Legible Entries – Entries and updates are legible to a reader other than the author.
  • Medication Allergies and/or Adverse Reactions – Information on allergies and adverse reactions (or a notation that the patient has no known allergies or history of adverse reactions) are prominently displayed in the medical record.
  • Prescribed Medications – Maintain a list of prescribed medications which include dosages and dates of initial or refill prescriptions.
  • Updated Problem List – A dated problem list summarizing a patient’s significant illnesses, as well as medical and psychological conditions, will be maintained.
  • Presenting Complaints/Physical Examinations
  • The medical record contains an entry for each patient visit stating the reason for the visit and the applicable diagnosis/treatment plan.
  • Follow-up Care – Entries stipulate when the patient should return for follow-up care.
  • Laboratory Results – Laboratory results are reviewed and initialed by the health care professional.
  • Tobacco, Alcohol and Substance Use Disorder – For patients age 14 and older, there are appropriate entries made concerning the use of cigarettes and alcohol, and substance use disorder (including anticipatory guidance and health education).
  • Medical History – Past medical history, including serious accidents, operations and illnesses are prominently documented for patients who have had three or more visits.
  • Immunization Records – Childhood immunization records are present for children under the age of 14 years.
  • Growth Chart – Create and maintain a growth chart for pediatric patients.
  • Advance Directives – Information on advance directives is noted in the medical record for all Medicare Advantage members, including a completed copy of the directive or member’s decision not to execute.
  • Provider List – Physicians and other health care professionals involved in the patient’s care can be easily identified in the patient’s chart.
  • Preventive Services/Risk Screening – Each patient record includes documentation that age-appropriate preventive services were ordered and performed or that the physician discussed age-appropriate preventive services with the patient and the patient chose to defer or refuse them. Physicians should document that a patient sought preventive services from another physician (e.g., Ob/Gyn, cardiologist, etc.) and include results of such services as reported by the patient.

Medical Record Retention Requirements

Physicians and other health care professionals are required to maintain medical and business records for a minimum of 10 years for all Medicare Advantage members and 7 years for Commercial members.

MEDICAL RECORDS FOR QUALITY-OF-CARE COMPLAINTS

Horizon BCBSNJ is required to investigate member complaints, including those that allege inadequate care was received from a participating physician, other health care professional or facility. Complaints that include potential medical quality-of-care issues will be referred to our Quality Peer Review Committee (which is comprised of Horizon BCBSNJ medical directors and participating physicians) for further review.

Upon receipt of a member complaint that includes a potential medical quality-of-care issue, the provider may be asked to submit medical records and documentation to help the committee investigate the complaint. The provider is required to respond to such requests under the terms and conditions of their Participation Agreement and an obligation to follow our policies and procedures.

Failure to comply with a request for medical records and/or additional documentation required to investigate a medical quality-of-care complaint is a very serious issue and may result in termination for cause from Horizon BCBSNJ’s networks.

Physicians and other health care professionals who do not respond to such requests in a timely manner will have a notation placed in their credentialing file for consideration at the time of recredentialing.

We also advise impacted members of their provider’s failure to comply with requests for medical records and make these members aware of their right to file a complaint with the New Jersey State Board of Medical Examiners.

We acknowledge and appreciate that the great majority of our medical record requests are responded to promptly and efficiently.

NCQA AND HEDIS®

As the National Committee for Quality Assurance (NCQA) gathers data from health plans for its nationwide comparisons, Horizon BCBSNJ gathers data from your medical offices. Contracted practitioners/providers are encouraged to cooperate with the collection and evaluation of data and participate in Horizon BCBSNJ’s quality improvement activities. Performance data may be used for quality improvement activities. A provider’s diligence in ensuring his or her patients are appropriately treated or screened will be reflected in the plan’s report card made available to the general public through the NCQA’s website.

HEDIS® (Healthcare Effectiveness Data and Information Set) is the measurement tool used by the nation’s health plans to evaluate their performance in terms of clinical quality and customer service. It is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare health care quality.

We appreciate your cooperation in helping us to meet these measurement requirements.

Note: You may not charge Horizon BCBSNJ for copies of medical records when they are requested for medical review, claim review or as part of a medical record or HEDIS audit.