Quality Improvement Activities
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Published: October, 2001
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Many of PBH's QI activities require the cooperation of practitioners
and providers. PBH relies on the collection of data from numerous
sources, including but not limited to, member satisfaction
surveys, provider satisfaction surveys, claims data to help
determine utilization trends, grievances, appeals and audits
of clinical records and practice locations. Treatment record
audits are conducted on a routine basis for all PBH contracted
Preferred Group Practices, and selected individual practitioners.
PBH stipulates in its contracts with all practitioners and
providers that access must be allowed to the treatment records
if requested.
PBH monitors utilization trends and quality issues for the
entire network as well as for individual practitioners, Preferred
Group Practices and facilities. Whenever a serious deficiency
in performance is identified, the matter is referred to the
appropriate PBH entity for review and initiation of a Corrective
Action Plan (CAP) if indicated. In these instances, a letter
is sent to the provider identifying the problem, requesting
action be taken by the provider to correct the problem, and
requesting a written response from the provider. An evaluation
of the effectiveness of the corrective action is conducted
after a specified time period, as determined by the issuing
PBH entity in collaboration with the PBH Network Management
Department. If this process fails to resolve the problem,
the issue is referred to the Peer Review Committee. (For further
information on the reduction or termination of provider privileges,
or the denial of credentialing or recredentialing, please
refer to Credentialing
/Recredentialing.)
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Key Points
- PBH requires cooperation of practitioners and providers
in QI activities.
- Treatment record audits are conducted on a regular
basis for Preferred Group Practices and individual
practitioners.
- Treatment record audits and medical records requests
can be required of all contracted providers and practitioners
by PBH per the contractual agreement.
- Serious deficiencies in provider or practitioner
performance are referred to Network Management and
Quality Improvement Departments for assessment and
corrective action.
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