2016 Quality Program Description
Virginia Premier’s Quality Program’s primary objective is to continuously improve the quality of care provided to members, which enhance the overall health status of Virginia Premier members. Improvement in health status is measured through the use of Health Employer Data Information Set (HEDIS®) information, internal quality studies, ongoing regulatory and accreditation compliance and focusing on the overall health outcomes of our population. Virginia Premier is committed to improving the communities where the members live through participation in public health initiatives on both the national and local levels, and achievement of public health goals. A detailed description of our program can be downloaded here.
2015 Quality Program Evaluations
The annual Quality Program Evaluation is an evaluation of the previous years’ quality improvement activities and provides a mechanism for systematically completing an analysis of VPHP performance and to define meaningful and relevant quality activities for our members. Through a structured review of the various clinical, service, administrative and educational initiatives, the program evaluation serves to emphasize the accomplishments and effectiveness of the Quality Program as well as identify barriers and opportunities for improvement within the process. An Executive Summary of our evaluation can be downloaded here.
What’s Important in Quality
Virginia Premier Quality Satisfaction Committee: The Virginia Premier Quality Satisfaction Committee was developed and implemented to comprehensively oversee, manage and work in collaboration with departmental leaders to effectively define, measure, analyze, improve and control outcomes related to key quality satisfaction activities, at both the member and practitioner level, such as grievances/complaints, plan integration of member and practitioner/provider feedback (when appropriate) at the advisory meetings and satisfaction survey outcomes.Cultural Competency:
Please tell your doctors to take the VPHP Challenge and complete a Cultural Competency Course Today! The purpose of the course is to help your doctors treat and care for members of diverse ethnic backgrounds. Each practitioner is highly encouraged to complete the class. The practitioners that complete the class will be recognized. If you are interested in obtaining more information on cultural competency, please contact the Quality Department at 1-800-727-7536.
- NCQA Provider Race, Language Form This form allows us to match members with requested practitioners who speak another language, or are of another nationality.
- Cultural Competency Quiz This quiz assesses the provider’s cultural awareness.
- Practitioner Golden Globe Award This form allows the nomination of an outstanding practitioner.
- Provider Measure Overview This document explains the HEDIS measures in detail, the identified age group, and it informs the provider about the screenings that will need to be done for the measurement period.
- HEDIS Quick Reference Billing Codes This forms lists various cpt codes for well visits, BMI’s, and immunizations.
- HEDIS Quick Reference Clinical Reference This is a quick guideline that lists the HEDIS measures and the required components/ screenings that need to be done during the measurement period.
- Change PCP Form This form is used to ensure the member has accurate PCP information on their insurance card.
- CAHPS Provider Handout This document defines Consumer Assessment of Health Care Providers and Systems and the benefits of effective communication.
- Immunization Schedule This document provides the immunization schedule from birth to 18 years of age.
- Immunization Data Transfer This form explains how providers can electronically transfer immunization data directly to the Virginia Department of Health.
- Well-Care Anticipatory Guidance This document provides examples of health and development, physical exam, and health education / anticipatory guidance.
- EPSDT and Anticipatory Guidance Chart This sample charting form for providers explains how to document a visit.
- BMI- Adults This form allows you to determine your Body Mass Index (BMI).
- Growth Chart Boys This file is a Body Mass Index chart for Boys age 2 to 20 years old.
- BMI Growth Chart Girls This file is a Body Mass Index chart for girls age 2-20 years old.
- Case Management & Disease Management Brochure This brochure explains VPHP’s Disease Management Program and Case Management Programs.
- Checklist for Diabetic Patient This is a checklist for providers to monitor the member’s progress.
- Lead Testing Guidelines This file helps identify those children at risk for lead exposure.
- Lead Screening Poster This poster reminds you when a lead screening is needed, areas where lead is evident, and complications associated with lead poisoning.
- Site Survey Standards
- Practitioner Office Site Survey Tool
- Medical Record Standards
- Adult Medical Records Review
- Pediatric Medical Records Review
Clinical Practice Guidelines
- Asthma Guidelines
- COPD Guidelines
- Diabetes Mellitus Guideline
- Heart Failure Disease
- Pain Strategy Clinical Practice Guidelines
- Prenatal-Normal Pregnancy
- Preventive Care Guideline
- Preventive Prenatal High Risk Guideline
- Screening for Depression in Diabetes
- Sickle Cell Pain Crisis Guideline
- Smoking Cessation Guideline
- Stable Coronary Artery Disease Guideline
- Weight Loss Drugs for Adults & Criteria
2015 Credentialing Program Description: Virginia Premier’s Credentialing Program is comprehensive to ensure that its practitioners and providers meet the standards of professional licensure and certification. The process enables Virginia Premier to recruit and retain a quality network of practitioners and providers to serve its members and ensure ongoing access to care.
Virginia Premier’s Preferred Application is the Council for Affordable Quality Healthcare (CAQH):
- The service is FREE for practitioners.
- Each practitioner submits one application to one central database to meet the needs of all of the health plans and networks participating in the CAQH effort. To obtain a listing of health plans or to register, please visit http://www.caqh.org/.
- Practitioners may easily update their information online or via fax 24 hours a day, 7 days a week.
- If you do not participate with the CAQH, you will need to complete this application.
- Other Reminders that will prevent the delay of processing existing credentialing applications:
- Please remember to re-attest your CAQH Application quarterly.
- Please make certain that your license and DEA certificates are current at all times and are faxed to CAQH.
- Please notify Virginia Premier immediately once you have obtained your board certification, if applicable.
- Virginia Premier must obtain a minimum of five years of relevant work history through the practitioner’s application or CV; relevant experience includes work as a health professional; if the practitioner has practiced fewer than five years from the date of verification of work history, it starts at the time of initial licensure; experience practicing as a non-physician health professional (e.g., registered nurse, nurse practitioner, clinical social worker) within the five years should be included.
- A gap exceeding six months must be reviewed and clarified either verbally or in writing; a CV or application must include the beginning and ending month and year for each position in the practitioner’s employment experience; if a practitioner has had continuous employment for five years or more, then there is no gap and no need to provide the month and year, if the year meets the intent; verbal communication must be appropriately documented in the credentialing file; a gap in work history that exceeds one year must be clarified in writing.
- Please fax any credentialing related documents to 804-819-5171.
Practitioner’s Rights(1) TO CORRECT ERRONEOUS INFORMATION Virginia Premier’s policy does not preclude the right of practitioners to review and correct erroneous information obtained to evaluate their credentialing application from outside primary sources to include, but not limited to, malpractice insurance carriers, state licensing boards, etc., with the exception of references, recommendations or other peer-review protected information, if applicable. Virginia Premier is not required to reveal the source of information if the information is not obtained to meet organizational credentialing verification requirements or if the law prohibits disclosure. Virginia Premier’s policies and procedures state the practitioner’s right to correct erroneous information submitted by a source. The policy clearly states:
- The time frame for changes
- The format for submitting corrections
- The person to whom corrections must be submitted
- The documentation of receipt of the corrections
- How practitioners are notified of their right to correct erroneous information (avenues identified under Right to review information, above, are appropriate).
Upon acceptance by the Committee, each new practitioner and provider, as applicable, is provided training materials in compliance with Privacy Rule workforce training mandates of the Health Insurance Portability and Accountability Act of 1996 (HIPPA).(2) TO REVIEW INFORMATION Virginia Premier ensures that practitioners can access their own information obtained by VIRGINIA PREMIER during the credentialing process and used to support their credentialing application. Practitioners shall be notified, in writing, of this right via one or more of the following methods:
- Practitioner and/or Provider manuals
- Provider Newsletters
- Other Suitable Method
(3) TO BE INFORMED OF APPLICATION STATUS Virginia Premier’s written policy is to notify a practitioner of his/her application status, upon request. The process allows for phone calls, emails, letters, or faxes from practitioners. If either the credentialing staff or another department receives a request it shall be responded to within 72 hours of receipt. If another department receives a request, it will be routed to the Credentialing Department within one business day for follow-up and resolution, by the Credentialing staff, within 72 hours of initial receipt.
The Credentialing Department staff can advise the practitioner, once key information is verified, of the following information via phone or in writing, if requested by the practitioner:
- The date the application was received
- The status of the application – pending for additional information, etc.
- The date the application is tentatively scheduled to be presented to the Committee
- Answer any questions the practitioner may ask
Prior to disclosing any practitioner information via phone, as credentialing information is confidential, the following must be verified by the Credentialing staff and confirmed by the practitioner:
- Practitioner’s full name
- Practitioner’s primary office location
- Practitioner date of birth
- The name, city and state of the school the practitioner graduated
- Year practitioner joined the Virginia Premier Network
(4) TO BE NOTIFIED OF HIS/HER RIGHTS Each prospective and existing practitioner has the right to be notified of the aforementioned rights and will be notified via once of the methods listed under “Right to Review Information” described above.
(5) TO BE INFORMED OF THE APPEAL PROCESS AND APPEAL AN ADVERSE DECISION (BASED ON QUALITY REASONS) RELATED TO NETWORK PARTICIPATION Each prospective and existing practitioner has the right to be informed regarding the steps to appeal an adverse action, based on quality issues, in the event that participation status is altered.
To speak with someone in Credentialing, call 800-727-7536, option 8. Please fax any credentialing related documents to 804-819-5171.
- The practitioner’s license must be unrestricted, current and valid.
- The practitioner must be in good standing with Virginia Premier
- Good Standing: Most recent site visit score and medical record keeping scores meet the Plan’s thresholds; the practitioner submits quality information, re-credentialing applications, etc. per policy; and the practitioner continuously follows and adheres to VPHP’s policies and procedures.
- The practitioner cannot have grievances/complaints filed against him/her in the last 12 months prior to being published in the Newsletters and/or on the Website.
- The practitioner cannot have any quality issues in the last 12 months noted on the National Practitioner Data Bank Report, Department of Health Professions – Board of Medicine Sanctions Report, the Office of the Inspector General Sanctions Report or Department of Medical Assistance Services (DMAS).
- The practitioner cannot be involved in any pending legal issues that could impede the safe care of members.
- The practitioner must have documentation of taking a cultural competency course.
- The practitioner or nominator must complete the designated form and submit with the accolade and/or an explanation and examples of current professional innovations in health care that have improved the health status of recipients.
- Exemption: A practitioner may be exempt from random site visits and random medical record keeping reviews. (Only applicable if the practitioner has received the NCQA Physician Practices Award.)
- Recognition: Members, colleagues, and the public will have access to this information via member and provider newsletters and notification of the recognition will be on Virginia Premier’s website within 30 days from PGA award presentation: www.vapremier.com.
- Quality Commitment: Practitioner exemplifies commitment to quality, excellence and continuous health education.
- Receipt of an Award from VPHP (awarded to one practitioner annually): VPHP encourages each practitioner that is recognized to proudly display the award in his or her office where visible.