Quality Management
Program Description
SummaCare works with providers, members and employers to provide a comprehensive, community-focused health plan that maximizes service and choice. We are committed to a thorough and effective Quality Management Program that follows the principles of Continuous Quality Improvement to improve the care and services members receive.
Major goals and objectives of the program include:
- Promoting and building quality into the structure and processes of our organization
- Monitoring to ensure high quality care and service
- Promptly identifying opportunities for improvement with actions for resolution
To fulfill these goals and efficiently utilize resources, the Quality Management Program is integrated across all functional areas and product lines including HMO, POS, PPO and Medicare. Attention is given to areas of high volume and/or high-risk in terms of either patient care or services. Integration occurs via interdisciplinary meetings and work groups to analyze all available data. Quality indicators for both clinical studies and operational metrics are objective and measurable, based on existing knowledge and clinical experience and are reviewed ongoing to assure the need for changes are identified promptly. After data is collected and analyzed, action plans are developed which delineate the person or department responsible for the completion of each task, as well as the timeframe for completion.
Subjects of ongoing review and data collection include:
- Outcomes of care and compliance to nationally recognized standards of care
- Continuity & coordination of care
- Customer Service call timeliness
- Provider Service call timeliness
- Physician credentialing activities
- Utilization of Medical and Behavioral Health services in all care settings
- Claims Processing
- Eligibility Processing
- Appeals
- Sales
- Member and Physician Satisfaction Surveys
- Complaints
- Access and Availability
- Special studies
- Accreditation
- Regulatory activities
In 2009, the quality improvement program focused on enhancing the customer experience and promoting preventative health and wellness through targeted interventions. To assist members in obtaining preventive screenings and optimal care for chronic conditions such as diabetes and cardiovascular diseases, SummaCare initiated a new form of outreach. The outreach includes an annual preventive health letter, which identifies recommended services for you and your family, and a care opportunity letter, sent to members if we have not received any claims by mid-year for the recommended tests and services. Letters will be followed up by a reminder phone call later in the year for members with continued care opportunities.