AZ
"7. MAINSTREAMING
OF AHCCCS MEMBERS...
If the Contractor
identifies a problem involving discrimination by one of its providers,
it shall promptly intervene and implement a corrective action plan.
Failure to take prompt corrective measures may place the Contractor in
default of its contract." Arizona Contract, pages 20-21.
"16. PERFORMANCE
MEASUREMENT...
The Contractor
will be required to submit a corrective action plan and may be subject
to sanctions if:
a)
the Contractor has not achieved the AHCCCS statewide performance level
for any measure and has failed to show adequate improvement, or
b)
if the Contractor’s rate has declined and fallen below the AHCCCS statewide
performance level for any measure.
Corrective action plans must be received by the Office of the Medical Director within 30 days of receipt of notification from AHCCCS. AHCCCS may conduct one or more follow-up on-site reviews to verify compliance with a corrective action plan." Arizona Contract, page 27.
"E. Corrective
Action
1. When
Corrective Actions Are Necessary
The CONTRACTOR
agrees to implement corrective action as specified by the DEPARTMENT when
quality assurance monitoring including but not limited to…determines the
need for such corrective action. In addition, if the DEPARTMENT determines
that the CONTRACTOR has not provided services in accordance with the Contract
or within expected professional standards, the DEPARTMENT will request
in writing that the CONTRACTOR correct deficiencies or identified problems
by developing a corrective action plan.
2. Initial
Response by CONTRACTOR
The CONTRACTOR
has 20 working days from the date the DEPARTMENT mails through certified
mail, its written request for the CONTRACTOR to respond to the problems
identified and will either
a.
submit a corrective action plan,
b.
submit a letter summarizing the CONTRACTOR's disagreements with the DEPARTMENT's
finding...
3. Submission
of Corrective Action to DEPARTMENT
a.
Acceptance of Corrective Action Plan...
b.
When Corrective Action Plan Requires Revision
If the CONTRACTOR submits a corrective action plan, but the DEPARTMENT determines the corrective action plan requires revisions, the CONTRACTOR will have 20 working days to submit a revised plan from the date the DEPARTMENT mails, through certified mail, the request for the revised plan.
4. Initial
Appeal of DEPARTMENT's Findings
If the CONTRACTOR
disagrees with the DEPARTMENT's findings and wishes to appeal those findings,
the CONTRACTOR will submit in writing to the DEPARTMENT within the established
time frame a detailed explanation of the disagreement...
5. Formal
Hearing
If the DEPARTMENT
upholds its decision that a corrective action plan is required, the CONTRACTOR
may file a request for a formal hearing with the DEPARTMENT within 30 days
for the date the DEPARTMENT mails, through certified mail, a letter upholding
its decision...
6. CONTRACTOR
Unwilling or Unable to Implement Corrective Action Plan
If the CONTRACTOR
is unwilling or unable to implement the corrective action plan to the satisfaction
of the DEPARTMENT, the CONTRACTOR will be subject to the following sanction:
A $500 penalty of each working day, beginning on the first day after the DEPARTMENT verbally notifies the CONTRACTOR that the corrective action plan has not been implemented, and continuing until the day the CONTRACTOR successfully demonstrates to the DEPARTMENT that it has implemented the plan...
7. Collection
of Financial Penalties
The DEPARTMENT
may deduct any financial penalties assessed by the DEPARTMENT from the
monthly payment to the CONTRACTOR." Arizona Contract, pages D3-D6.
AZBH
"12. APPOINTMENT
STANDARDS...
ADHS shall
ensure its subcontracted RBHAs provide appointments as follows: ...
ADHS shall
monitor compliance with these standards and shall require a corrective
action plan when appointment standards are not met." Arizona Behavioral
Health Contract, page 18.
CA
"ARTICLE II
- DEFINITIONS...
P. Corrective
Actions means specific identifiable activities or undertakings of the Contractor
which address program deficiencies or problems identified by formal audits
or DHS monitoring activities." California Contract, pages 2-3.
"6.4.43 MIS/Data
Correspondence
Contractor
shall ensure, that upon written notice by DHS of any problems related to
the submittal of data to DHS, or any changes or clarifications related
to Contractor's MIS system, that Contractor shall submit to DHS a Corrective
Action Plan with measurable benchmarks within thirty (30) calendar days
from the date of the postmark of DHS' written notice to Contractor.
Within thirty (30) days of DHS' receipt of Contractor's Corrective Action
Plan, DHS shall approve the Corrective Action Plan or request revisions.
Within fifteen (15) days after receipt of a request for revisions to the
Corrective Action Plan, Contractor shall submit a revised Corrective Action
Plan for DHS approval." California Contract, page 86.
"6.5.5.6 Corrective
Actions
Contractor
shall ensure that Primary Care sites with major, uncorrected deficiencies
are not allowed to begin operation. In the event a Primary Care site
develops such deficiencies subsequent to the commencement of operations,
Contractor shall require such site to cease providing services to Members;
provided that such site may not be required to cease providing services
in the event DHS and Contractor agree to a plan of corrective action to
be implemented by the site, and such plan is being implemented to the satisfaction
of DHS." California Contract, page 95.
CO
"IX. MONITORING
AND SITE REVIEWS...
F. A
written report of the site visit shall be transmitted to the Contractor
within thirty (30) calendar days of the Site Review. The Contractor
shall be allowed thirty (30) days to review the preliminary report and
respond to the findings. The final report shall indicate areas of
strength, suggestions for improvement, and required actions...
G. The Contractor shall respond to any required actions, if necessary, with a corrective action plan within thirty (30) calendar days of the final written report, specifying the action to be taken and time frames. The corrective action plan is subject to approval by the Department. Department review staff shall monitor progress on the corrective action plan until the Contractor is found to be in complete compliance. Department staff shall notify the Contractor in writing when the corrective actions have been completed, accepted, and the Contractor is considered to be in compliance with Department regulations and this Contract.
H. Where it is reasonable and advisable to do so, the Department may extend the time frame for corrective action. The Department may also reduce the time frame for corrective action if delivery of Covered Services for Members is adversely affected. For corrective action plans affecting the provision of Covered Services to Members, the Contractor shall ensure that Covered Services are provided to Members during corrective action periods." Colorado Contract, pages 36-38.
"XV. QUALITY
ASSURANCE…
B. External
Review...
5. The
Contractor shall provide a quality improvement plan, upon request of the
Department or its external review contractor, within thirty (30) days.
The plan is subject to approval by the Department." Colorado Contract,
pages 54, 56.
"XIX.
COMPLAINT PROCESS...
3. Evaluation
of the Contractor's Complaint System
a. The Contractor shall periodically sample Member Complaints, including requests to change Primary Care Physicians.
b. Using data provided by the Department about Member Disenrollment rates, the Contractor shall analyze reasons for Disenrollment that are within the control of the Contractor to improve, and respond to problems causing voluntary Disenrollment.
c. The Contractor shall participate in or cooperate with Member satisfaction surveys directed or conducted by the Department. In addition, the Contractor shall report to the Department results of internal satisfaction surveys of Members designed to identify areas of satisfaction and dissatisfaction.
d. The Contractor shall take corrective measures to address areas of dissatisfaction and measure the effectiveness of actions taken. Analysis of Complaints and other measures of Member satisfaction shall be forwarded to the Department's quality assurance staff as necessary to comply with the quality assurance standards.
e. The Contractor shall collect, aggregate, and report data on Member Complaints, requests to change Primary Care Physicians, and Member satisfaction according to the specifications, tables, and time frames as determined by the Department, in consultation with the Contractor." Colorado Contract, pages 60-61.
CT
"STANDARDS FOR
INTERNAL QUALITY ASSURANCE PROGRAMS FOR HEALTH PLANS...
Standard II:
Systematic Process of Quality Assessment and Improvement...
E. Implementation
of remedial/corrective actions
The QAP includes
written procedures for taking appropriate remedial action whenever, as
determined under the QAP, inappropriate or substandard services are furnished,
or services that should have been furnished were not.
These written
remedial/corrective action procedures include:
1.
Specification of the types of problems requiring remedial/corrective action.
2.
Specification of the person(s) or body responsible for making the final
determinations regarding quality problems.
3.
Specific actions to be taken.
4.
Provision of feedback to appropriate health professionals, providers and
staff.
5.
The schedule and accountability for implementing corrective actions.
6.
The approach to modify the corrective action if improvements do not occur.
7.
Procedures for terminating the affiliation with the physician, or other
health professional or provider.
F. Assessment
of effectiveness of corrective actions
1.
As actions are taken to improve care, there is monitoring and evaluation
of corrective actions to assure that appropriate changes have been made.
In addition, changes in practice patterns are tracked.
2.
The MCO assures follow-up on identified issues to ensure that actions for
improvement have been effective…" Connecticut Contract, Appendix
I, pages 1-4.
DE
"12.2 Internal
Quality Assurance and Utilization Management Program
The MCO must
have an internal written quality assurance plan (QAP) that monitors, assures,
and improves the quality of care delivered over a wide range of clinical
and health service delivery areas. The QAP will be reviewed semiannually
by the State or more frequently if necessary. Emphasis should be placed
on, but need not be limited to, clinical areas relating to maternity, pediatric
and adolescent development (including EPSDT), family planning and well-women
care, as well as on key access or other priority issues for Medicaid patients
such as reducing the incidence of sexually transmitted diseases, acquired
immune deficiency syndrome, smoke related illnesses, etc.
Contractors
must satisfy at a minimum: ...
(g) Describe
methodologies and mechanisms for monitoring and auditing provider performance,
identifying deficiencies, addressing deficiencies with corrective action,
monitoring of corrective actions for intended results, and communicating
of all findings to providers" Delaware RFP, pages II.70-II.71.
"External Quality
Assurance Reviews
DSS will contract
with independent, external evaluators to examine the quality of care provided
by MCOs. The State will amend the existing contract with its EQRO
for the Title XIX program. The amendment will clearly define the
need to keep the populations and associated reporting separate.
The MCO will
be required to cooperate with any external quality independent assessment
of its performance which has been duly authorized by DSS. Independent
assessments shall include, but not be limited to, the federally required
reviews of
(1) access
to care, quality of care, cost effectiveness, and the effect of case management;
(2) the contractor's
quality assurance procedures, implementation of the procedures, and the
quality of care provided; and (3) consumer satisfaction surveys.
The MCO agrees to assist in the identification and collection of any data or medical records to be reviewed by the independent assessors and/or DSS. The contractor shall ensure that the data, medical records, and work space are available to the independent assessors or DSS at the contractor's work site.
DSS will monitor each MCO's adherence to QARI standards through one or more of the following mechanisms: ...
The MCO shall submit a corrective action plan to resolve any performance or quality of care deficiencies identified by the independent assessors and DSS as determined necessary by DSS." Delaware RFP, Appendix A (SCHIP), pages A.29-A.30.
FLMH
"2.18
Quality Assurance Requirements...
A. The
contractor must have a quality assurance system in place to monitor
and assure that services provided are sufficient in quantity, of acceptable
quality and meeting the needs of the enrolled population. The plan
must have a quality assurance review authority which shall: ...
9. Report
action plans;
10. Implement
improvement activities...
B. The
plan shall provide for quality assurance staff which has responsibility
for...
2. Prioritizing
problem areas for resolution and designing strategies for change...
C. The
plan's quality assurance program shall have peer review component and a
peer review authority responsible for the following scope of activities:
...
3. The
authority to implement corrective action when deemed necessary..."
Florida Mental Health RFP, page 42.
HI
"45.000 Monitoring
and Evaluation
45.010
Internal QAP Monitoring...
Upon completion
of its review, DHS will submit a report of its findings to the health plan.
The health plan shall submit a plan of action to correct, evaluate, respond
to, resolve and follow-up on any identified problems reported by the DHS.
45.020 External
Monitoring...
The health
plan shall submit a plan of action to correct, evaluate, respond to, resolve
and follow-up on any identified problems reported by the audit."
Hawaii RFP, pages 63-64.
HIBH
"30.420
Availability and Accessibility of Providers...
The BHMC plan
shall monitor compliance with appointment standards and shall have a corrective
action plan when appointment standards are not met." Hawaii Behavioral
Health RFP, page 16.
"45.010
Internal OIP Monitoring
DHS shall monitor
the BHMC plan to assure that its internal QIPs are structured and operating
in accordance with the standards for the internal QIPs.
DHS will evaluate specific aspects of the QIP by a variety of methods. It will review complaint and grievance logs, evaluate complaints from advocacy groups, providers. agencies, and members/representatives, validate that QIP utilization management, concurrent review, and prior authorization procedures are being implemented with an understanding of the behavioral health benefits allowed under QUEST and taking into consideration the medical necessity of the services for the member. Also, DHS will evaluate whether procedures to ensure access to care, continuity of care and coordination of care and other QIP activities which are part of the plan's written QIP are being implemented...
Upon completion of its review, DHS will submit a report of its findings to the BHMC plan. The BHMC plan shall submit a plan of action to correct, evaluate, respond to, resolve and follow-up on any identified problems reported by the DHS." Hawaii Behavioral Health RFP, pages 51-52.
IL
"EXHIBIT A
Quality Assurance
(QA)
1. All services provided by or arranged by Contractor to be provided shall be in accordance with prevailing professional community standards. Contractor shall establish a program that systematically and routinely collects data to review which includes quality oversight and monitoring performance and patient results. The program shall include provision for the interpretation of such data to Contractor's practitioners. Contractor shall have in effect a program consistent with the utilization control requirements of 42 CFR Part 456. This program will include, when required by the regulations, written plans of care and certifications of need of care.
2. Contractor
shall establish procedures such that Contractor shall be able to demonstrate
that it meets the requirements of the HMO Federal qualification regulations
(42 CFR 417.106 and/or the Medicare HMO/CMP regulations (42 CFR 417.418(c)).
These regulations require that an HMO/CMP have an ongoing fully implemented
Quality Assurance program for health services that: ...
• includes
written procedures for taking appropriate remedial action whenever, as
determined under the quality assurance program, inappropriate or substandard
services have been furnished or services that should have been furnished
have not been provided…" Illinois HMO Contract, pages A1-A2.
"4. Contractor
shall provide Department with the QAP written guidelines which delineate
the QA process, specifying: ...
d. Implementation
of Remedial/Corrective Actions - The QAP shall include written procedures
for taking appropriate remedial action whenever, as determined under the
QAP, inappropriate or substandard services are furnished, or services that
should have been furnished were not. Quality assurance actions which result
in remedial or corrective actions shall be immediately forwarded by Contractor
to the Department.
Written remedial/corrective
action procedures shall include:
• specification
of the types of problems requiring remedial/corrective action;
• specification
of the person(s) or body responsible for making the final determinations
regarding quality problems; specific actions to be taken;
• provision
of feedback to appropriate health professionals, providers and staff; the
schedule and accountability for implementing corrective actions;
• the
approach to modifying the corrective action if improvements do not occur;
and
• procedures
for notifying a Primary Care Provider group that a particular physician
licensed to practice medicine in all its branches is no longer eligible
to provide services to Beneficiaries.
e. Assessment of Effectiveness of Corrective Actions Contractor shall monitor and evaluate corrective actions taken to assure that appropriate changes have been made. In addition, Contractor shall track changes in practice patterns. Contractor shall assure follow-up on identified issues to ensure that actions for improvement have been effective and provide documentation of same." Illinois HMO Contract, Exhibit A, page A4.
IN
"4.6.9
Quality Improvement and Utilization Review Program
The MCO must
monitor, evaluate, and take effective action to identify and address any
needed improvements in the quality of care delivered to members by all
providers in all types of settings, in accordance with the provisions specified
in Section 4.6.9.1 of this RFP. In addition, the MCO must have a
utilization review program in place that meets the requirements specified
in Section 4.6.9.2 of this RFP.
4.6.9.1
Quality Improvement Program and Reporting Standard...
The MCO must
meet the following reporting requirements:
The MCO’s QI
program shall be based on an annual written plan, specific to Hoosier Healthwise
members, that meets OMPP’s approval, and includes: goals; structure; authority;
responsibilities; scope; methods of evaluation (such as methods used in
bi-annual quality of care chart audits which the MCO is required to perform);
and mechanisms for acting upon improvement information generated. The plan
must be submitted to OMPP and the MCO monitoring contractor within ninety
(90) days of the effective date of the contract. The QI plan must
include but not limited to the following:
*
Goals and objectives. Goals shall include: ...
- The development and implementation of corrective action plans…" Indiana
RFP, pages 4-33, 4-34.
IA
"4.2.1.3.
Early Periodic Screening Diagnosis and Therapy (EPSDT)
The HMO shall
provide all Covered Services to Enrollees eligible for Early and Periodic
Screening, Diagnosis, and Treatment (EPSDT) according to the periodicity
schedule found in Addendum I including: ...
If the HMO's screening rate is less than 80%, the HMO shall be required by the Department to submit a corrective action plan identifying improvements/ enhancements of existing outreach, education, and case management activities which will increase the HMO's screening rate.
The corrective action plan shall be submitted within ninety (90) days after notification by the Department or no later than April 1 of the Contract Year. The HMO shall submit EPSDT/Well Child reports, as required in Article 7.1 of this Contract, demonstrating the effectiveness of the corrective action plan. If no change is noted within six months of implementing the corrective action plan, the plan shall be reviewed by the HMO with appropriate revisions." Iowa Contract, pages 20-21.
"4.2.1.4.
Immunizations...
If the HMO
reports immunization rate as less than the 90% goal as reported in encounter
data, the HMO shall submit a corrective action plan identifying improvements/enhancements
to outreach, education, and case management activities to increase the
HMO's immunization rate.
The corrective action plan shall be submitted within ninety (90) days after notification by the Department or no later than the first day of May of the Contract Term. The HMO shall measure and submit reports as outlined in Article 7.1 demonstrating the effectiveness of the corrective action plan, the HMO shall make appropriate revisions to the plan." Iowa Contract, pages 21-22.
IABH
"E. Provider
Corrective Action (Proposal Section 7A.2.5)
MBC of Iowa
will conduct retrospective reviews of all substance abuse providers in
accordance with section 4B.5 of the Iowa Plan RFP...
Step 3.
Providers have 30 days to develop action plans for MBC of Iowa review.
Step 4.
MBC of Iowa will consider the corrective action plan and determine if an
on-site visit is required or if follow-up documentation by the provider
will suffice. If the corrective action is sufficient, no further
response by MBC of Iowa or the provider is needed. If the response
is not sufficient, action will be taken by MBC of Iowa to assure documentation
and contract compliance requirements are met…" Iowa Behavioral Health
Contract, page 57.
"CONTINUOUS
QUALITY IMPROVEMENT IN THE IOWA PLAN (from RFP Section 5.16)...
The Contractor
shall: ...
5) If
the Departments determine that the Contractor is not in compliance with
the requirements of the annual Quality Improvement Goals, the Contractor
shall prepare and submit a corrective action plan to Departments for approval.
The plan and its implementation shall be reviewed by the Departments and
by the Advisory Committee." Iowa Behavioral Health Contract, page
95.
KY
"7.5.1 Quality
Improvement System...
(a)
The Quality Improvement Plan shall contain: ...
(9)
Mechanisms for assessing and taking corrective actions, when performance
measures or benchmarks are not achieved or study findings deem corrective
action to be appropriate…If the Department determines benchmarks have not
been achieved, a corrective action plan shall be submitted to the Department
by The Partnership within two months of notification. Improvement
shall be shown by the partnership within three months following initiation
of the corrective action plan." Kentucky RFA, pages 34-35.
"7.5.2
Quality Improvement Reports and Timelines
The
Partnership shall annually review, evaluate and modify as necessary, the
quality improvement
system, .including the medical record system; data collection system and
system for checking provider credentials, as well as all quality improvement
policies and procedures; clinical care standards; practice guidelines and
patient protocols; provider incentive plans; and program capacity; member
utilization of services; access to covered services; and treatment outcomes.
The Partnership shall prepare a report to the Department, detailing the
annual review; completed activities and corrective actions; corrective
actions which are recommended or in progress; and the results of all clinical,
administrative, provider and member satisfaction surveys conducted during
the immediate preceding year. The report shall set forth any proposed modifications
to the quality improvement system or policies and procedures. Any such
modifications shall be approved, in writing, by the Department prior to
implementation. See Attachment XIV for specific time frames and report
requirements." Kentucky RFA, page 40.
"Expansion and
or Changes in the network
If at
any time, a Partnership determines that its Provider Network is not adequate
to comply with the access standards specified above, The Partnership shall
notify the Department for Medicaid Services of this situation and submit
a corrective action plan to remedy the deficiency. The corrective
action plan shall describe the deficiency in detail, including the geographic
location and specific regions where the problem exists, and identify specific
action steps to be taken by The Partnership and time frames to correct
the deficiency." Kentucky RFA, page 51.
ME
"E. PCP
AND SPECIALIST ACCESS...
3. Timely
Access to Health Care Services. The Contractor shall contractually require
its network providers to make Health Plan services accessible on a timely
basis in accordance with medically appropriate guidelines, and consistent
with generally accepted standards of care...Providers shall schedule appointments
at reasonable times and in accordance with the following requirements:
...
If any of the above timeliness standards are not achievable in a particular community, then it will initially be sufficient to meet the community standard of care regarding access timelines. However, in such cases the Contractor's Quality Improvement Committee must then work with the community providers in formulating an action plan for meeting the above standards and forward such plan to the Department for review and approval." Maine Contract, pages 27-28.
"3.5 QUALITY
IMPROVEMENT AND UTILIZATION MANAGEMENT
A. QUALITY
IMPROVEMENT PROGRAM
The Contractor
must implement a system approved by the Department to promote quality and
accessibility of care to members, and that meets federal requirements under
Title XIX of the Social Security Act (42 CFR 434.34) including methods
to monitor and evaluate the care delivered to members according to generally
accepted community standards of care and practice. The system must include...the
assurance that appropriate corrective action is taken in response to problem
areas...
4. Credentialing
and Recredentialing.
a. The
Contractor shall maintain written policies and procedures, approved by
its Governing Body or its formal designee, that at a minimum address for
all physicians and other licensed practitioners who fall under its scope
of authority and action: ...
(v) process
for consideration of corrective actions for non-compliant providers in
the reappointment process, incorporating:
- quality of
care standards
- clinical
practice guidelines
- utilization
standards
- medical records
documentation standards
- ethics/citizenship
standards
- cooperation
with plan goals and objectives
- provider
access
- member complaints
- member satisfaction
surveys..." Maine Contract, pages 30, 32.
MD
"10.09.65.03...
P. An
MCO shall submit a corrective action plan required as a result of the annual
audit or the drug use management program and a formulary review as follows:
(1) Within
45 days of receiving the results of the annual audit or the drug use management
program and formulary review, the MCO shall submit for the Department's
approval a plan detailing a corrective course of action to rectify any
deficiencies identified in the audit or review resulting in a compliance
rating below the rating established for that year in any element of the
systems performance review, the clinical care review, or the drug use management
program and formulary program review; and
(2) At
the Department's request, the MCO shall participate in any re-review by
the Department of the deficiencies identified during the audit or review
to ensure implementation of all corrective action." Maryland COMAR
10.09.65.03.
".01 Sanctions...
B. Corrective
Action.
(1) Subject
to §B(2) and (3) of this regulation, before imposing a sanction pursuant
to §A of this regulation, the Department shall permit an MCO an opportunity
to take corrective action in accordance with a plan approved by the Department.
(2) The
MCO shall submit a corrective action plan within a time frame specified
by the Department.
(3) The
Department is not required to provide an MCO with an opportunity for corrective
action before imposing a sanction if the Department determines that there
is a likelihood of immediate and substantial harm to the MCO's enrollees
if implementation of the sanction is delayed." Maryland COMAR 10.09.73.01.
MABH
"SECTION REIMBURSEMENT...
(4)
Subsequent to the Division's review and approval of the corrective action
plan and the timetable for its implementation, the Contractor shall implement
the corrective action plan within fourteen calendar days." Massachusetts
MH/SAP Contract, page 36.
"2.06
Network Management
The Contractor
shall: ...
2.06.04
Develop and submit at the beginning of each Contract Year to the Division
for its prior review and approval, a plan identifying the Network Management
Department's Provider improvement goals, corrective action plan(s) for
the year, and methods to be employed to monitor corrective action plan(s),
implementation and progress." Massachusetts MH/SAP Contract, Appendix
B, pages 19, 20.
"5.03
Service Authorization and Utilization Review
The Contractor
shall:
5.03.09 Submit
to the Division for prior review and approval and implement on the Full
Service Start Date, service denial policies and procedures which shall
include, but not be limited to, the following requirements:
b. design
and implement corrective action plans for Providers, who receive more that
a 10% denial rate for prospective, concurrent, or retrospective service
authorization requests, including referral of these Providers to the Network
Management staff for education and technical assistance." Massachusetts
MH/SAP Contract, Appendix B, pages 34, 38-39.
MN
"Section 7.1.
Internal System.
The HEALTH
PLAN shall provide for an internal quality assurance (QA) system consistent
with federal requirements under Title XIX of the Social Security Act, and
as required pursuant to Minnesota Statutes, Chapters 62D, 62M and 62N and
related rules, including Minnesota Rules, Part 4685.1100 to 4685.1130.
The HEALTH PLAN's system shall provide for review by appropriate health professionals of the process followed in the provision of health services, utilize a system for data collection of performance and patient results, provide interpretation of such data to the practitioners and provide for instituting needed changes with identified practitioners.
The HEALTH PLAN shall utilize a Continuous Quality Improvement (CQI) model in supporting practitioner changes in practice patterns and administrative process.
The HEALTH PLAN's
QA system shall include documentation and appropriate review and/or conduct
of:
Section 7.1.6.
Appropriate corrective actions." Minnesota Contract, pages 74-75.
MO
"2.16.4
Internal Procedures: ...
a. Internal
policies and procedures must: ...
6) Provide
for making appropriate changes and improvements. When problems in
quality of care issues are found, write a corrective action plan including
specific outcomes, timelines for correction, and assign a specific staff
person to be responsible for ensuring compliance and follow-up."
Missouri RFP, page 81.
NE
"15.2 Overall
Quality Framework: The plan shall develop and implement, under the Department’s
oversight and monitoring, a continuous Quality Assurance/Quality Improvement
(QA/QI) Program that meets the following guidelines: ...
(e) Provides
for making necessary changes through corrective action plans." Nebraska
Contract, page 120.
"15.14 Corrective Action: When the QAC of the Department determines the inappropriate care or substandard services have been provided, or services which should have been furnished have not been provided, the QAC shall be responsible for communicating concerns identified and outlining the corrective action necessary.
15.14.1 Role of the Medical Director: The Medical Director of the Department shall be responsible for working with the plan/provider to develop and implement a corrective action plan, if appropriate.
15.14.2 Final
Actions by the QAC: The QAC is responsible for communicating a summary
of the case, findings and corrective action recommended to the Department’s
contract manager for any additional action. The QAC can recommend/initiate
the following actions:
(a)
Letter of information;
(b)
Letter of censure, requested plan/provider response;
(c)
Site visit, with correction action plan required;
(d)
100% review of all cases;
(e)
Second opinion for all surgical cases;
(f)
Plan/provider be closed to new members;
(g)
Suspension; and
(h)
Termination." Nebraska Contract, page 131.
NEBH
"13.2
Overall Quality Framework: The PHP shall develop and implement, under
the Department’s oversight and monitoring, a continuous Quality Assurance/Quality
Improvement (QA/QI) Program, that meets the following guidelines: ...
(e) Provides
for making necessary changes through corrective action plans." Nebraska
Behavioral Health Contract, page 85.
"13.13 Levels of Concern: Quality of care or service concerns identified through the QA /QI process will be categorized for assessment, intervention and resolution as follows:
(a) Serious: The problem resulted in, or contributed to, the death of a patient or seriously jeopardized the health of a patient (though the eventual outcome may have been satisfactory). Immediate intervention by the Medical Director of the PHP and the Department is required at the provider and the entity level.
(b) Substantial: The problem involved a significant deviation from the Community/National standards of care with respect to diagnosis, treatment, or expected outcome; direct intervention by the Medical Director of the PHP and the Department at the provider and entity level is required.
(c) Minor: The problem had a minimal or inconsequential effect on the health status of the member; intervention not required, continue to monitor to identify trends; direct intervention at the provider level not required.
(d) Service: The problem involves the healthcare delivery system and did not directly impact the medical intervention not required for health of the client but did impact the client’s satisfaction. Ongoing monitoring to identify trends required.
13.14 Corrective Action: When the QAC of the Department determines the inappropriate care or substandard services have been provided, or services which should have been furnished have not been provided, the QAC is responsible for communicating concerns identified and outlining the corrective action necessary.
13.14.1 Role of the Medical Director: The Medical Director of the Department is responsible for working with the PHP/provider to develop and implement a corrective action plan, if appropriate.
13.14.2
Final Actions by the QAC: The QAC is responsible for communicating
a summary of the case, findings and corrective action recommended to the
Department’s contract manager for any additional action. The QAC
can recommend/initiate the following actions:
(a)
Letter of information;
(b)
Letter of censure, requested PHP/provider response;
(c)
Site visit, with correction action plan required;
(d)
100% review of all cases;
(f)
Plan/provider be closed to new members;
(g)
Suspension; and
(h)
Termination." Nebraska Behavioral Health Contract, pages 94-95.
NV
"E.
IMPLEMENTATION OF REMEDIAL/CORRECTIVE ACTIONS
The QAP includes
written procedures for taking appropriate remedial action whenever, as
determined under the QAP, inappropriate or substandard services are furnished,
or services that should have been furnished were not.
These written
remedial/corrective action procedures include:
1.
Specification of the types of problems requiring remedial/corrective action;
2.
Specification of the person(s) or body responsible for making the final
determinations regarding quality problems;
3.
Specific actions to be taken;
4.
Provision of feedback to appropriate health professionals, providers and
staff;
5.
The schedule and accountability for implementing corrective actions;
6.
The approach to modifying the corrective action if improvements do not
occur;
7.
Procedures for terminating the affiliation with the physician, or other
health professional or provider." Nevada Contract, pages 60-61.
NH
"Article VII
Quality Improvement
Program
7.1 The Contractor shall ensure the delivery of quality care with the primary goal of improving the health status of Enrollees. The Contractor shall maintain an active commitment to Continuous Quality Improvement/Quality Management in all aspects of its service delivery...
(3) The QIP
or related document must include the following written procedures for implementing
appropriate remedial action for:
(a)
Problem identification.
(b)
Specification of the person or body responsible for correcting the problem.
(c)
Specific actions to be taken.
(d)
Corrective Action Plan implementation schedule.
(e)
Corrective Action Plan evaluation.
(f)
Modifying the Corrective Action Plan if improvements do not occur.
(g)
Reporting significant noncompliance." New Hampshire General Service
Agreement, page 27.
NJ
"ARTICLE 15
QUALITY MANAGEMENT
AND UTLIZATION REVIEW...
15.4
The contractor shall establish, implement, and adhere to a written Quality
Management Program (QMP)…
15.6
The contractor's QMP shall include the following standards: ...
B.
Systematic process of quality assessment and improvement including: ...
5. Implementation of remedial/corrective actions;
6. Assessment of effectiveness of corrective actions..." New
Jersey Contract, pages 76-77.
"STANDARDS FOR
INTERNAL QUALITY ASSURANCE PROGRAMS OF HMOs, HIO, and PHPs CONTRACTING
WITH MEDICAID...
STANDARD II:
SYSTEMATIC PROCESS OF QUALITY ASSESSMENT AND IMPROVEMENT - ...
The QAP has
written guidelines for its quality of care studies and related activities
which include: ...
E.
Implementation of remedial/corrective actions -
The
QAP includes written procedures for taking appropriate remedial action
whenever, as determined under the QAP, inappropriate or substandard services
are furnished, or services that should have been furnished were not.
These
written remedial/corrective action procedures include:
1. Specification of the types of problems requiring remedial/corrective
action;
2. Specification of the person(s) or body responsible for making
the final determinations regarding quality problems;
3. Specific actions to be taken;
4. Provision of feedback to appropriate health professionals, providers
and staff;
5. The schedule and accountability for implementing corrective actions;
6. The approach to modifying the corrective action if improvements
do not occur;
7. Procedures for terminating the affiliation with the physician,
or other health professional or provider.
F.
Assessment of effectiveness of corrective actions -
1. As actions are taken to improve care, there is monitoring and
evaluation of corrective actions to assure that appropriate changes have
been made. In addition, changes in practice patterns are tracked.
2. The managed care organization assures follow-up on identified
issues to ensure that actions for improvement have been effective…"
New Jersey Contract, pages 203-207.
OH
"Background...
Program Objectives
Assuring access
to medically necessary health services as well as the quality of care delivered
to Medicaid recipients enrolled in managed care plans are of primary concern
to ODHS. Plan performance is monitored through: ...
* The
development and monitoring of corrective action plans for certain problems
or deficiencies…" Ohio RFP, page 5.
"5101:3-26-071
MANAGED CARE PLAN: INTERNAL QUALITY ACTIVITIES...
(e) CORRECTIVE
ACTION PROCEDURES. THE QP MUST INCLUDE THE MCP'S WRITTEN POLICIES
AND PROCEDURES FOR TAKING APPROPRIATE CORRECTIVE ACTION WHEN THERE IS AN
OCCURRENCE OF UNDELIVERED, INAPPROPRIATE OR SUBSTANDARD HEALTH CARE SERVICES.
THE MCP MUST DISTRIBUTE THESE POLICIES AND PROCEDURES TO PARTICIPATING
PROVIDERS. WRITTEN CORRECTIVE ACTION PROCEDURES MUST INCLUDE:
(i) TYPES OF PROBLEMS;
(ii) ENTITY RESPONSIBLE FOR MAKING THE FINAL DETERMINATIONS;
(iii) A SCHEDULE FOR THE IMPLEMENTATION OF ACTIONS TO BE TAKEN BY
THE MCP AND HEALTH CARE PROFESSIONALS, PROVIDERS AND STAFF.
(iv) PROVISION OF FEEDBACK TO THE APPROPRIATE HEALTH PROFESSIONALS,
PROVIDERS AND STAFF;
(v) THE APPROACH TO MODIFYING THE CORRECTIVE ACTION IF IMPROVEMENTS
DO NOT OCCUR;
(vi) THE PROCESS TO MONITOR CORRECTIVE ACTIONS TO ASSURE THAT APPROPRIATE
CHANGES HAVE BEEN IMPLEMENTED AND ARE EFFECTIVE. ANY CHANGES IN PRACTICE
PATTERNS MUST BE TRACKED;
(vii) PROCEDURES FOR THE SUSPENSION, REDUCTION, OR TERMINATION OF
PRACTITIONER PRIVILEGES WITH THE MCP THAT REQUIRE:
(a) THE
REPORTING OF SERIOUS DEFICIENCIES TO THE APPROPRIATE AUTHORITIES; AND
(b) IMPARTIAL
PROVIDER APPELLATE PROCESS." Ohio RFP, Appendix E, OAC 5101:3-26-071,
pages 1-5.
ORMH
"E. Quality
Assurance/Quality Improvement(QA/QI) Requirements...
2. Quality
Improvement Work Plan
Contractor
shall develop and submit to Division a written Quality Improvement Work
plan within 30 days of the effective dates of this agreement. Contractor
shall obtain Division approval of such plan within three calendar months
following the effective dates of this agreement.
a. Contractor shall develop and monitor progress toward measurable Objectives, Indicators, and Benchmarks in the following domains: Access to Services; Quality of services; Integration and Coordination of Services; Prevention, Education, and Outreach; and Outcomes.
b. Contractor shall work with Division to identify at least three activities to measure compliance with the applicable terms and requirements of this Agreement.
c. Contractor shall submit a Quality Improvement workplan report describing process towards objectives and benchmarks 30 days after the termination of this agreement." Oregon Mental Health Contract, pages 26-27.
"Contractor shall cooperate with Division in the development of a corrective action plan to bring Contractor performance in compliance with this Agreement or state and federal laws, rules and regulations." Oregon Mental Health Contract, page 54.
PA
"M…Quality Assurance...
3…Quality Assurance...
c. Quality
Assurance (QA)...
The HMO shall
implement its QA plan and: ...
• Implement
Corrective action plans required by the Department, the Department Of Health,
or the External Reviewers…" Pennsylvania RFP, pages 74-78.
PABH
"b. Utilization
Management (UM)...
As part
of its utilization management function, the MCO must have processes to…undertake
corrective action." Pennsylvania Behavioral Health RFP, page 64.
"g. External
Independent Assessment...
The
MCO must submit a corrective action plan, as determined by the Department,
to resolve any performance or quality of care deficiencies identified as
a result of the independent evaluation and/or by the Department."
Pennsylvania Behavioral Health RFP, pages 65-66.
SC
"11 QUALITY
ASSURANCE, MONITORING AND REPORTING
11.1
Quality Assurance...
The
Contractor shall agree to external quality assurance evaluation, review
of quality assurance meeting minutes and annual medical audits to ensure
that it provides quality and accessible health care to Medicaid HMO Program…
If deficiencies are identifies the Contractor must formulate a corrective action plan incorporating a timetable within which it will correct deficiencies identified by such evaluations and audits. SCDHHS must prior approve the corrective action plan and will monitor the Contractor's progress in correcting the deficiencies in accordance with the approved plan and timetable for implementation." South Carolina Contract, pages 55-56.
TN
"2-17.
Changes Resulting From Monitoring and Audit
The
CONTRACTOR shall, as soon as is practical and no later than sixty (60)
calendar days after a notice of deficiencies is received, unless justified
and agreed upon by TENNCARE, comply with all recommendations made in writing
by TENNCARE, pursuant to Agreement items found not in compliance as a result
of any authorized monitoring report or audit. A written plan to correct
cited deficiencies and a time frame for completion of said plan must be
submitted to TENNCARE by the CONTRACTOR within fifteen (15) working days
after receipt of notice of deficiencies or as soon as practical, whichever
is the lesser. TENNCARE may extend or reduce the time frame for corrective
action where, in its opinion, it is reasonable and advisable to do so.
The CONTRACTOR shall be responsible for assuring corrective action when
a subcontractor's or provider's quality of care is inadequate...
In the event the CONTRACTOR fails to complete the actions required by the corrective action plan within the time frame specified, the CONTRACTOR agrees that TENNCARE shall assess the liquidated damages specified in Section 4-8. of this Agreement, or if the deficiencies are severe, that TENNCARE may terminate the Agreement for cause as described in Section 4-2. of this Agreement...
This Section shall apply to any corrective action requirements not otherwise specifically addressed." Tennessee Contract, page 56.
"GUIDELINES FOR INTERNAL QUALITY MONITORING PROGRAMS OF MANAGED CARE ORGANIZATIONS CONTRACTING WITH TENNCARE
STANDARD I:
WRITTEN QMP DESCRIPTION -
The organization
has a written description of its QMP. This written description meets
the following criteria: ...
G. Systematic
Process of Quality Assessment and Improvement...
5.
Implementation of Remedial/Corrective Actions -
The
QMP includes written procedures for taking appropriate remedial action
whenever, as determined under the QMP, inappropriate or substandard services
are furnished, or services that should have been furnished were not.
These
written remedial/corrective action procedures include:
a.
specification of the types of problems requiring remedial/corrective action;
b.
specification of the person(s) or body responsible for making the final
determinations regarding quality problems;
c.
specific actions to be taken;
d.
provision of feedback to appropriate health professionals, providers and
staff;
e.
the schedule and accountability for implementing corrective actions;
f.
the approach to modifying the corrective action if improvements do not
occur;
g.
procedures for terminating the affiliation with the physician, or other
health professional or provider…" Tennessee Contract, pages QCM-2-4.
UT
"E. Corrective
Action
1.
When Corrective Actions are Necessary
The
CONTRACTOR agrees to implement corrective action as specified by the DEPARTMENT
when quality assurance monitoring including but not limited to site reviews,
CONTRACTOR documentation reviews, data analysis, medical audits, or complaints/grievances,
determined the need for such corrective action. In addition, if the
DEPARTMENT determines the CONTRACTOR has not provided services in accordance
with the Contract or within expected professional standards, the DEAPRTMENT
will request in writing that the CONTRACTOR correct deficiencies or identified
problems by developing a corrective action plan.
2.
Initial Response by CONTRACTOR
The
CONTRACTOR has working days from the date the DEPARTMENT mails, through
certified mail, its written request for the CONTRACTOR to respond to the
problems identified and will either
1.
submit a corrective action...
3.
Submission of Corrective Action to Department
1.
Acceptance of Corrective Action Plan
If the CONTRACTOR submits a corrective action plan to the DEPARTMENT within
20 working days ... and the DEPARTMENT accepts the corrective action
plan, the plan DEPARTMENT will send written notice to the CONTRACTOR officially
approving the corrective action plan..." Utah Contract, Attachment
D, pages 3-4.
UTMH
"Article VI
COMPLIANCE/MONITORING...
B. Corrective
Action
The CONTRACTOR
agrees to implement corrective action as specified by the DEPARTMENT when
quality assurance monitoring including but not limited to onsite reviews,
CONTRACTOR documentation reviews, data analysis, medical audits, or complaints/grievance
determines the need for such corrective action. In addition, if the
DEPARTMENT determines that the CONTRACTOR has not provided services in
accordance with the CONTRACT or within expected professional standards,
the DEPARTMENT will request in writing that the CONTRACTOR correct
deficiencies or identified problems by developing a corrective action plan.
1.
The CONTRACTOR has 20 calendar days from the date the DEPARTMENT mails,
through certified mail, its written request for the CONTRACTOR to respond
to the problems identified and must either
(a) submit
a corrective action plan,
(b) submit
a letter summarizing the CONTRACTOR's disagreements with the Department's
findings, or
(c) request
in writing, an extension of the 20-day time frame. The CONTRACTOR
may only request an extension if it determines it must conduct a medical
records review or there are other extenuating circumstances. If the
CONTRACTOR fails to response in one of the above ways, the CONTRACTOR will
be subject to the following sanction:
A $500
penalty for each day, beginning on the first day after the 20-day time
period has expired, and continuing until the day a corrective action plan
is submitted to the DEPARTMENT.
a. If the CONTRACTOR submits a corrective action plan to the DEPARTMENT within 20 calendar days (or other agreed upon time frame) and the DEPARTMENT accepts the corrective action plan, the DEPARTMENT will send written notice to the CONTRACTOR officially approving the corrective action plan.
If the CONTRACTOR submits a corrective action plan, but the DEPARTMENT determines the corrective action plan requires revisions, the CONTRACTOR will have 20 calendar days to submit a revised plan from the date the DEPARTMENT mails, through certified mail, the request for a revised plan. The DEPARTMENT's letter will site the specific revisions to be made in the corrective action plan.
If the CONTRACTOR is unable or unwilling to submit to the DEPARTMENT within the established time frame, a revised corrective action containing the DEPARTMENT's requested revisions, the CONTRACTOR will be subject to the following sanction:
A $500 penalty for each day, beginning on the first day after the 20-day time period has expired, and continuing until the day a corrective action plan is submitted to the DEPARTMENT.
b. If the CONTRACTOR disagrees with the DEPARTMENT's findings and wishes to appeal those findings, the CONTRACTOR must submit in writing to the DEPARTMENT within the established time frame, a detailed explanation of the disagreement. If the DEPARTMENT agrees with the CONTRACTOR, the DEPARTMENT will provide written notification of its decision and will withdraw the request for a corrective action plan...
2. If the DEPARTMENT upholds its decisions that a corrective action plan is required, the CONTRACTOR may file a request for a formal hearing with the DEPARTMENT within 30 calendar days from the date the DEPARTMENT mails, through certified mail, a letter upholding its decision. If the $500 penalty has begun, it will discontent once the DEPARTMENT receives a formal hearing request from the CONTRACTOR.
If the outcome of the formal hearing is in favor of the CONTRACTOR, the DEPARTMENT will provide the CONTRACTOR with written notification that a corrective action plan is no longer required.
The DEPARTMENT will reimburse the CONTRACTOR any penalties the CONTRACTOR has paid to the DEPARTMENT that accrued beginning on day 21 from the date the DEPARTMENT mailed, through certified mail, the request for a corrective action plan, and ending on the day the request for a formal hearing is received by the DEPARTMENT.
If the outcome of the formal hearing is in favor of the DEPARTMENT, the CONTRACTOR must submit a corrective action plan, as determined by the formal hearing decision, within 20 calendar days of the date of the hearing decision, otherwise the CONTRACTOR will be subject to the following sanction:
A $500 penalty for each day, beginning on the first day after the 20-day time period has expired, and continuing until the day a corrective action plan that complies with the formal hearing decision is submitted to the DEPARTMENT. If the DEPARTMENT determines that the corrective action plan requires revisions, the CONTRACTOR will again be subject to a $500 penalty for each day beginning on the first day after the date the DEPARTMENT mailed, through certified mail, notification that the corrective action plan requires revisions and continuing until the day the DEPARTMENT receives the corrective action plan containing the DEPARTMENT's required revisions.
3. If the CONTRACTOR is unwilling or unable to implement a corrective action plan to the satisfaction of the DEPARTMENT, the CONTRACTOR will be subject to the following sanction:
A $500 penalty for each day, beginning on the first day after the date the DEPARTMENT mailed, through certified mail, notification to the CONTRACTOR that the corrective action plan has not been implemented, and continuing until the day the CONTRACTOR successfully demonstrates to the DEPARTMENT that it has implemented the plan.
The CONTRACTOR will be apprized of its right to request a formal hearing. If the CONTRACTOR decides to formally appeal the DEPARTMENT's decision that the corrective action plan has not been implemented, then the procedures detailed in number 2 above apply. If the outcome of the formal hearing is in favor of the DEPARTMENT, penalties will resume on the date of the formal hearing decision and continue until the CONTRACTOR complies with the decision of the formal hearing." Utah Mental Health Contract, pages 18-20.
WV
"5.2
Utilization Management...
As part of
its utilization management function, the MCP
must have processes
to identify utilization problems and undertake corrective action…"
West Virginia RFA, page 38.
"E. Implementation
of remedial/corrective actions
The DAP includes
written procedures for taking appropriate remedial action whenever, as
determined under the OAP, inappropriate or substandard services are furnished,
or services that should have been furnished were not.
These written
remedial/corrective action procedures include:
1. Specification
of the types of problems requiring remedial/corrective action.
2. Specification
of the persons) or body responsible for making the final determinations
regarding quality problems.
3. Specific
actions to be taken.
4. Provision
of feedback to appropriate health professionals, providers and staff.
5. The
schedule and accountability for implementing corrective actions.
6. The
approach to modify the corrective action if improvements do not occur.
7. Procedures
for terminating the affiliation with the physician, or other health professional
or provider.
F. Assessment
of effectiveness of corrective actions
1. As
actions are taken to improve care, there is monitoring and evaluation of
corrective actions to assure that appropriate changes have been made. In
addition, changes in practice patterns are tracked.
2. The
plan assures follow-up on identified issues to ensure that actions for
improvement have been effective." West Virginia RFA, Appendix E,
E3-E4.
WI
"Y. QUALITY
IMPROVEMENT (QI)...
10. External
Quality Review Contractor...
b. When
the professional review organization under contract with the Department
identifies an adverse health situation in which follow up is needed to
determine whether appropriate care was provided, the HMO will be responsible
for the following tasks: ...
3) submit a corrective action plan or an opinion in writing to the Department within 60 days that addresses the measures that the HMO and the provider intend to take to resolve the QI finding. HMO's final resolution of all potential Quality Improvement cases must be completed within six (6) months of HMO notification. A case is not considered resolved by the Department until the Department approves the response provided by the HMO and provider." Wisconsin Contract, pages 21, 28-29.