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Atlantis Health Plan is responsible for offering its members qualified and competent providers who will be accountable for the delivery of appropriate and medically necessary care and services. Atlantis Health Plan is responsible for regularly informing health care providers of information maintained by Atlantis Health Plan to evaluate the performance or practice of the health care professional.

Atlantis Health Plan has, with its providers, developed standards, criteria and methodologies to collect and analyze the health care professional profiling data to be used in the evaluation of the providers' performance. Atlantis Health Plan shall provide any such information and profiling data and analysis to the health care professionals. Atlantis Health Plan shall provide on a periodic basis and upon the request of the healthcare professional the information, profiling data, and analysis used to evaluate the provider's performance.

Any profiling data used to evaluate the performance or practice of a health care professional shall be measured against stated criteria or objectively compared to an appropriate group of health care professionals using similar treatment modalities and serving a comparable patient population. Each health care professional shall be given the opportunity to discuss the unique nature of the health care professional's patient population which may have a bearing on the health care provider's profile and to work cooperatively with Atlantis Health Plan to improve performance.

RESPONSIBILITY

It will be the responsibility of the Provider Services Unit of the Health Services Department to monitor the expiration dates of a provider's contract. The Provider Services Unit will request from the Health Services Management Unit a summary report evaluating the provider's performance against pre-established and pre-approved criteria 60 days prior to the planned presentation of a provider profile to the Credentialing Committee.

EVALUATION CATEGORIES

• Utilization Review

Studies are made of the use of ancillary services, medication, and inpatient and outpatient services to identify patterns including under-utilization or over-utilization of services. Outlier practices are targeted for further review.
• Quality Assurance and Improvement
  Continuous quality monitoring activities are designed to detect current or potential problems impacting patient care.

  Quality Improvement monitoring includes parameters from the following sources:

  • HEDIS
  • NYS DOH QARR
  • New York State Department of Health
  • National Committee on Quality Assurance (NCQA)

  Medical care evaluations promote the peer review process. Medical care audits provide an objective assessment of the processes and outcomes of care. Medical care evaluations (problem focused auditing) are performed to assure that the care provided by physicians and other health care professionals is appropriate, timely, effective and consistent with current national/community standards of practice.

• Preventive service audits are performed to determine provider compliance with professionally agreed disease prevention standards. Preventive service audits are designed to assure that members have access to and are utilizing available preventive health care services.
• On-site facility assessments are performed to assess the quality of care and services provided by prospective or contracted providers. Structural elements of quality care and services are evaluated. Components assessed during an on-site evaluation include:
  • facility appearance
  • environment
  • access to service
  • administrative structure and function
  • policy and procedure manuals
    • personnel
    • member care
    • fire/safety/emergency
  • member care services
  • ancillary services
  • medical records
  • safety and emergency procedures
• Access/Availability Assessment
  Access/Availability audits are performed to identify problems or potential problems relating to appointment availability and scheduling that result in delay of care and service and are based upon the Access and Availability Standards. Access audits are also performed to assure that members have access to needed care and services twenty-four hours a day, seven days a week.
• Claims Review
  This includes review of claims to detect and document coding errors including unbundling, fragmentation, upcoding, mutually exclusive procedures and duplicate, obsolete or invalid codes.
• Medical Records Standards and Review
  A medical record review must be conducted on at least a biennial basis for all primary care providers with more than 50 members and two years of participation in Atlantis Health Plan. The medical record review will be conducted so that the confidentiality of member records is protected. The provider is required to provide copies of the medical records to the Atlantis Health Plan offices for review. Provider medical records must be legible with current details organized and comprehensive in order to facilitate the assessment of the appropriateness of care rendered.
• Member Satisfaction Surveys
  Consumers tend to evaluate the quality of health care differently than health care practitioners; therefore, input from members is included in any evaluation of the quality of care and services. Members can provide information pertaining to the following:
  • Access and availability of care/services
  • Provider attitude/behavior
  • Satisfaction with care/service
  • Reasons for disenrollment
• Member Complaint and Grievance System
  Member complaints and grievances are used as a source of information about quality of care issues. Detailed documentation is required for tracking and reporting purposes and effective resolution.

Corrective action by the participating provider may be required. The Medical Director may take the following actions with individual practitioners to assure quality of care and service to members:

• Direct consultation and education with the practitioner
• 100% review of practitioner claims
• Mandatory second opinions for surgical care
• Limit practitioner privileges
• Impose "No New Patients" status
• Hold all payment of claims
• Conduct focused review of ambulatory or hospital care
• Suspend or terminate the Practitioner Agreement

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