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8.6.15 Monitoring Provider Performance
PCCM is responsible for monitoring quality of care and, if necessary, recommending that HHSC disenroll providers who do not meet plan requirements.
Among the indicators used to monitor PCCM providers' performance are:
• Client Comments and Complaints. The PCCM Complaints Department closely monitors the activities associated with client complaints as they relate to quality assurance and utilization management reviews for specific provider performances. The reports of these activities are used to trigger separate actions and inquiries about performance.
•Office Site Reviews. PCCM staff undertakes a variety of assessments as part of quality improvement activities and provider service activities. The results of these reviews are made part of the file of performance factors and indicators assessed during the recredentialing process.
•Compliance With 24-Hour Access Standards. PCCM staff conducts audits to assess the degree of compliance with Medicaid managed care access standards. Client comments and complaints may trigger reviews of specific providers. The results of these reviews are considered in the recredentialing process.
•Ability to Perform or Directly Supervise Ambulatory Primary Care Services for Clients. Provider performance is monitored on an ongoing basis. PCCM staff follows up evidence of poor performance and addresses identified problems immediately to ensure that high-quality care is delivered to plan clients.
•Admitting Privileges. PCCM staff verifies that each provider maintains membership on the medical staff with admitting privileges at a minimum of one accredited contracted hospital or has an acceptable (timely and complete transfer of patients and records) arrangement with a primary care provider who has such admitting privileges.
•Continuing Medical Education Credits. Provider Enrollment/Contracting and Credentialing staff monitors each provider's activities in the area of continuing medical education credits.
•Education Sessions. PCCM provides a series of educational sessions that include aspects of UM and case management. Provider contracts require that each primary care provider attend at least one educational session each year.
•Valid Drug Enforcement Administration (DEA) Certification. Proof of DEA certification must be submitted as part of the application process and will be maintained by PCCM in its credentialing files.
•Performance Within Scope of Individual Licensure and PCCM Credentialing. PCCM staff provider applications include a statement providing assurance that a certified registered nurse practitioner, nurse midwife, or PA will perform services only within the scope of his licensure, and that the individual will be disciplined immediately if this agreement is violated.
•Compliance with Fraud and Abuse Policy. PCCM will recommend to HHSC that a network provider be suspended immediately upon notification from any source that the provider:
•Has been terminated or suspended from participation in the Medicaid or Medicare Program.
•Has lost his or her license.
•Has been convicted of a criminal act.
PCCM employs the above indicators as part of its oversight function. Findings are cataloged and analyzed for patterns of performance that require special attention. Where warranted, the results are made part of the recredentialing process. Failure to adhere to the above standards of performance will be grounds for suspension or termination.
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