Corrective action plan
AL | CA | NE | PA | TX "Section Eighteen: Agency Monitoring...
I. Utilization Management Reports
The referral reports and enrollees utilization reports are two of the utilization management reports that will used by the Plan Monitoring Unit to review data...
Plan Monitoring will closely review physician access by monitoring 24 hours, 7 days a week phone coverage, waiting times for appointments and grievances from providers and recipients. Particular attention will be given to the 24 hours, 7 days a week phone coverage. Agency staff will randomly call physicians during office ours and after hours and on weekends. For physicians who do not respond within 24 hours, a warning letter will be sent asking for a plan of corrective action." Alabama PMP, page 23."X. Quality Assurance/Professional Review/Utilization Control System
1. Establish a Quality Assurance (QA) program. The Contractors' QA program will be designed to ensure that: ...
b. Quality of care problems are identified and corrected for all internal providers or subcontracting providers and follow-up is planned where indicated." California Contract, page 27."9.14 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 Department's QAC shall be responsible for communicating concerns identified and outlining the corrective action necessary.
9.14.1 Role of the Medical Director: The Medical Director of the Department shall be responsible for working with the Contractor/provider to develop and implement a corrective action plan, if appropriate.
9.14.2 Final Actions by the QAC: The Department's 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 Contractor/provider response;
(c) Site visit, with correction action plan required;
(d) 100% review of all cases;
(e) Second opinion for all surgical cases;
(f) Contractor/provider be closed to new members;
(g) Suspension; and
(h) Termination." Nebraska Contract, pages 107-108."4. Provider Monitoring
The contractor must develop and implement a plan to: ...j. Address non-compliance through a Corrective Action Plan (CAP). The CAP must be approved by the Department. At a minimum, the CAP must include:
(1.) Description of issue.
(2.) Corrective action.
(3.) Time frame for resolution.
(4.) Consequence of failure to comply." Pennsylvania Program Standards, Rider 2."B.3.2.3.2 Develop Contract Compliance Protocols...
d. The process must include steps to correct any deficiencies. These efforts should include, but are not limited to, counseling, a corrective action plan, and a follow-up review of the deficient area(s) after time for correction has taken place. The steps in this process should be bypassed if there is any evidence of fraudulent activity or if the enrollee's health or access to medically necessary care is in peril. In the event that an enrollee's health or access to care is in peril, the Contractor should immediately consult with the State Agency regarding the appropriate action to take. This may result in an immediate termination of the provider's agreement and a retroactive disenrollment. The Contractor would then work with the Enrollment Broker to enroll the affected recipients with another provider.e. Failure of the PCP or PHP or negotiated contractor to comply with the contract after an education-effort may result in contract termination. Information regarding the problem with a contract status recommendation must be referred to the State Agency for a decision on contract termination." Texas RFP, pages 29-31.
"B. 3. 2. 3. 7 Corrective Action
a. The contract compliance and quality assurance activities undertaken by the Contractor will undoubtedly result in the need for corrective action. The Contractor must develop protocols for corrective action steps to be taken whenever warranted by QI and contract, compliance activities. The corrective action should include a series of steps to assist the PCP in the performance of appropriate medical coverage for the PCP's enrollees. The goal is not to terminate PCPs from the program, but rather to assist them in providing medical care in a managed care setting while assuring both access and quality of care.b. It is possible that the corrective action plan will include a recommendation to terminate the PCP's contract. All terminations must be forwarded to the State Agency for approval before any action is taken. The Contractor's corrective action protocols must include emergency action in case of non-coverage of enrollees or in case of potential compromises to the health of enrollees." Texas RFP, page 31.