Provider Manual | Section 9
Section 9 contents
The purpose of the Health Plan of San Mateo’s (HPSM’s) Quality Improvement (QI) Program is to establish methods for systematically ensuring all members receive high quality health care. Through the QI Program and in collaboration with HPSM providers, HPSM strives to continuously improve the structure, processes, and outcomes of its health care delivery system.
HPSM’s QI Program has a commitment to quality that relies on HPSM senior management oversight and accountability and integrates the activities of all departments in meeting program goals and objectives. The QI Program involves members, participating providers, regulators, plan sponsors and evaluators in the development, evaluation, and planning of quality activities.
HPSM incorporates continuous quality improvement methodology that focuses on the specific needs of HPSM customers. It is organized to identify and analyze significant opportunities for improvement in care and services, to develop improvement strategies and to systematically track whether these strategies result in progress towards established benchmarks or goals. Focused QI Program activities are carried out on an ongoing basis to ensure that quality of care issues are identified and corrected. Quality studies and monitoring activities are reported through the quality committee structure to HPSM’s governing body. The QI Program Description is reviewed and updated annually.
HPSM conducts site reviews to ensure that all primary care provider sites are in compliance of the standards of the California Department of Health Care Services (DHCS)/Managed Care Quality and Monitoring Division (MCQMD). Additionally, site reviews are performed to ensure that the site provides appropriate primary health care services, has consistent processes that support the coordination of care, maintains patient safety standards and practices, and operates in compliance with local, state, and federal regulations. Site reviews are performed using the guidance provided in DHCS’s All Plan Letter (APL), 22-017, which can be found here: https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2022/APL22-017.pdf
There are three components of the site review process:
- Facility Site Review (FSR)
- Medical Record Review (MRR)
- Physical Accessibility Review (PAR)
HPSM conducts Facility Site Reviews (FSRs) for new Medi-Cal primary care physicians at the time of initial credentialing, at least every three years thereafter per California Department of Health Care Services (DHCS) guidelines, and as part of the re-credentialing process, regardless of the status of other accreditation and/or certifications.
The FSR and MRR are scored reviews. DHCS-Certified Nurse Reviewers conduct the FSR and MRR and score them with standardized DHCS guidelines and audit tools.
The FSR focuses on physical aspects of the site for basic regulatory requirements in areas including:
- Office Management.
- Clinical Services.
- Preventative Services.
- Infection Control.
The MRR is conducted three to six months following initial member assignment, and every three years thereafter. The MRR focuses entirely on the medical record for regulatory requirements in areas including:
- Coordination of Care.
- Pediatric Preventative Health Services.
- Adult Preventative Health Services.
- OB/CPSP Preventative Health Services.
HPSM conducts a Physical Accessibility Review for all existing and new primary care providers. The Physical Accessibility Review is not a scored review and focuses entirely on the physical accessibility of the site that provides care to all HPSM members, including Seniors and Persons with Disabilities (SPDs). Sites include:
- Primary care provider sites.
- Community-based adult service sites.
- High-volume specialist sites.
- Other ancillary sites as appropriate.
A Physical Accessibility Review is generally conducted in conjunction of the FSR process, however, it is also required as an independent review process for specialists and allied providers serving a high volume of members who are part of the SPD population. Physical Accessibility Reviews are completed during the initial site review process and every three years thereafter. The onsite evaluation includes these areas:
- Exterior building.
- Interior building.
- Exam Room.
- Exam table/weight scales.
The review establishes if the facility has basic access, or limited access for members with disabilities.
FSR and MRR Scoring
A minimum passing score of 80% on both the FSR and MRR is required. Primary care provider sites that score 79% and below in either the FSR or MRR survey for two consecutive reviews must score a minimum passing score in the next/third review for both the FSR and MRR. Sites who do not score a minimum of 80% for the third consecutive review are subject to removal from the HPSM network. Additionally, new members cannot be assigned to primary care providers that score 79% or below in either the FSR or MRR on a subsequent site review until HPSM has verified that the provider has corrected the deficiencies and the corrective action plan is closed.
A pre-contractual provider who scores 79% and below will not be recommended for credentialing completion or contract approval until a passing score is achieved and correction of any identified deficiencies are verified. Prior to being approved as a network provider, a non-passing provider must be re-surveyed and pass the FSR and MRR.
Corrective Action Plans
Any Corrective Action Plans (CAPs) that result from the scored FSR and MRR surveys must be addressed within the established CAP timelines. HPSM is dedicated to the success of its partnering providers and assists with CAPs as needed by providing resources, education, and answering any questions. Primary care providers that are non-compliant or do not meet the CAP timelines established in the regulatory requirements may not be recommended for credentialing/re-credentialing and/or are subject to removal from HPSM’s network.
Providers who move to a new site or open an additional office site must undergo a site review at their new location. The site review must be completed as soon as possible after the provider’s move to the site or the provider’s notice to HPSM (whichever is later), but no later than 30 calendar days after the date the new site was opened for business (or HPSM’s notification date). The site review for relocated offices must be completed prior to the provider’s re-credentialing date.
Providers who are added to a practice site, which has a current site review, will only require a medical record review to be credentialed.
HPSM reviews sites more frequently when it determines this to be necessary, based on findings from monitoring, evaluation or Corrective Action Plan (CAP) follow-up needs. Additional site reviews may be performed pursuant to a request from the Peer Review Committee, the Quality Improvement and Health Equity Committee, or the Commission. Additional reviews may also be done at the discretion of the Medical Director or the Quality Nurse, after discussion with the Medical Director, if patient safety or compliance with applicable standards is in question.
DHCS conducts separate site reviews to validate HPSM’s site review and medical record review processes. HPSM is notified approximately four weeks in advance of DHCS-conducted site reviews, and HPSM will notify the selected providers in advance of the site reviews, whether the site review is conducted by DHCS or by HPSM. However, all primary care providers enrolled in the Medi-Cal program through HPSM are subject to unannounced onsite site reviews.
“Focused Site Reviews” may be performed in between the three-year review period to investigate problems identified through monitoring activities, or to follow up and validate the resolution of corrective action plans (CAPs). The focused review is a targeted audit of one or more specific site or medical record review survey areas and is not substituted for the full scope survey.
For more information on the Site Review Process including regulatory guidelines, audit tools and standards, and additional resources, please visit: https://www.hpsm.org/provider/resources/medical-record-and-facility-site-reviews/
Initial Health Appointment (IHA)
The Initial Health Appointment (IHA) is a requirement for all new Medi-Cal members enrolled with the Health Plan of San Mateo (HPSM). An IHA is a comprehensive assessment completed during a new member’s initial encounter with their primary care provider. HPSM requires providers to schedule an IHA visit with all new members on their panel list. This office visit helps establish care with new patients and helps providers understand the patient’s medical history and to assess any specific needs.
During the IHA, the primary care provider assesses and manages the acute, chronic, and preventative health needs of the member. The IHA must be completed within 120 days of enrollment into HPSM and documented in the medical record (an exception is made if member’s record contains complete information updated within the previous 12 months as determined by the primary care provider).
Components of an IHA
To meet DHCS’s requirements, an IHA must be performed by a provider within the primary care medical setting and be provided in a way that is culturally and linguistically appropriate and documented in the member’s medical record. An IHA must include a history of a member’s present illness, past medical history, social and behavioral health history and review of organ systems including an oral assessment. The IHA must also include an identification of risks, an assessment of need for preventative screens or services and health education, and the diagnosis and plan for treatment of any disease.
Primary care providers are required to make at least three attempts and document efforts to contact a member to schedule an IHA. These attempts must include at least one telephone contact and one written contact. If the provider is unable to reach the member or the member refuses an appointment, contact HPSM Member Services for assistance. The primary care provider should attempt to perform the IHA at subsequent member office visits, even if the 120-day period has lapsed.
For more information on IHA requirements and finding newly assigned members, please visit https://www.hpsm.org/provider/resources/initial-health-assessment
Healthcare Effectiveness Data and Information Set (HEDIS)
The Healthcare Effectiveness Data and Information Set (HEDIS) is a set of standardized performance measures designed to ensure that purchasers and consumers of health care services have the information they need to compare the performance of managed health care plans. HPSM is required by the Department of Health Care Services (DHCS) to perform quality measure studies for our Medi-Cal line of business. The Centers for Medicare and Medicaid Services (CMS) requires HPSM to perform quality studies for HPSM’s CareAdvantage program as well. Beginning in 2024, the Department of Managed Healthcare (DMHC) requires HPSM to conduct quality studies on our Medi-Cal and Healthworx lines of business. DHCS, DMHC and CMS use HEDIS measures to assess how well HPSM is providing quality services for our members.
There are two phases to each HEDIS study. HPSM’s data analysts perform the first phase by examining HPSM’s administrative data (e.g., claims data and enrollment information). This type of information may not fully reflect the actual care provided to our members when the services are capitated and not separately billed to HPSM and/or cannot be captured via claims or encounter submission. In phase two, HPSM staff, or contracted vendor staff, undertake an extensive examination of the relevant members’ medical records in provider offices. In these ways, data is collected that provides information to DHCS, DMHC, CMS and San Mateo County about the level of clinical care, preventive care, access to care and utilization of services that HPSM members receive. HPSM network providers are expected to provide timely access to medical records for members selected for HEDIS review.
Clinical Practice Guidelines and Best Practices
Clinical practice guidelines help to improve the quality of care for our members by providing HPSM physicians with systematically developed, evidence-based guidelines on best practices.
These guidelines assist both physicians and patients in decision-making regarding appropriate health care for specific clinical circumstances.
HPSM promotes the use of practice guidelines that have been developed using nationally recognized scientific evidence published in peer reviewed journals, released by specialty societies or academies, or promulgated by national advisory committees.
The guideline topics and resources are evaluated and updated at least annually, with the input of HPSM’s Quality Improvement and Health Equity Committee (QIHEC) and any other interested HPSM provider. Providers can access the clinical guidelines in the Provider Resources section of the HPSM website: https://www.hpsm.org/provider/resources/guidelines
- National Heart, Lung, and Blood Institute: https://www.nhlbi.nih.gov/resources
- United States Preventive Services Task Force: https://www.ahrq.gov/clinic/uspstfix.htm
HPSM has multiple avenues for physicians to contribute to its quality program. The most important way is through high quality and preventive care to HPSM members. Without our providers, HPSM could not offer services to our members.
HPSM’s Medical Directors and Provider Network Manager have an “open door” policy. Contact information is freely available to physicians. When any physician has a quality improvement suggestion or a quality concern, they are encouraged to contact these or any other HPSM staff to share their thoughts, via phone, email or letter.
There are also formalized ways for HPSM providers to participate in quality activities with the plan. These are through the San Mateo Health Commission quality advisory groups.
Peer Review Committee (PRC)
- Serves in an advisory capacity to HPSM, providing community physician insight and feedback on the quality initiatives of the plan.
- Reviews areas in need of quality improvement identified via HEDIS or other comparable measurements and assists HPSM in developing potential interventions.
- After quality improvement initiatives are developed, provides feedback on the tools, materials, incentives, etc. that are developed to implement the initiative.
- As HPSM practicing physicians, provide real-world feedback on how they, their colleagues and their patients are accepting/participating in HPSM’s quality initiatives, to help HPSM continuously improve its efforts and outcomes.
- The PRC meets regularly to review all HPSM credentialing recommendations and to address HPSM credentialing concerns (e.g., when a potential provider does not appear to meet or no longer appears to meet HPSM credentialing requirements). The PRC meets confidentially to provide a peer-based resource for reviewing provider issues related to credentialing, quality of care issues or similar concerns.
- Where indicated, the PRC makes recommendations (e.g., regarding sanctions) to the San Mateo Health Commission for final decision-making. Any sanctions or actions affecting individual providers are protected by Evidence Code 1157.
Committee membership is reflective of the provider network. It includes a physician member of the San Mateo Health Commission, a physician of the San Mateo Medical Center, a maximum of nine HPSM contracting physicians, the majority of whom are primary care physicians from the adult and pediatric community (representing care of adults and children) and at least three specialists representing different disciplines.
Quality Improvement and Health Equity Committee (QIHEC)
Purpose/Responsibilities: The Quality Improvement and Health Equity Committee (QIHEC) establishes strategic direction, recommends policy decisions, analyzes, and evaluates the results of QI activities, and ensures practitioner participation in the QI Program through planning, design, implementation, or review. The QIHEC ensures that appropriate actions and follow-up are implemented and evaluates improvement opportunities. The QIHEC meets and reports at least quarterly to the Commission.
Membership: The QIHEC is a multi-disciplinary committee, the membership includes:
- At least one Commission member.
- Chief Medical Officer or delegate Medical Director.
- Quality Improvement Director.
- Practicing network physicians.
- Support staff and guests will be invited to attend the meetings as reporting requirements dictate.
San Mateo Health Commission
- Delegates management of the QI Program to HPSM's Chief Executive Officer while retaining overall authority and responsibility for program implementation, continuity, and effectiveness.
- Monitors QIP strategies and activities outlined in HPSM's QI Program Annual Report/Evaluation and Work Plan, and at the time of any substantive revision.
- Monitors and reviews HEDIS results and establishes activities/opportunities for improvement.
- Reviews the identification of Quality of Care issues and development of Quality Improvement Projects to establish interventions/activities.
- Reviews quarterly reports about monitoring and evaluation activities performed because of the QI Program implementation, discusses these reports as necessary, raises any issues of concern and requests follow-up as indicated.
- Identifies opportunities to improve care and service, directs action to be taken, or resolves problems when indicated, independent of any other quality activities.
Members are appointed by the San Mateo County Board of Supervisors and include:
- Two members of the San Mateo County Board of Supervisors.
- The San Mateo County Manager or his/her designee.
- An HPSM contracted physician.
- A public representative of senior and/or minority communities in San Mateo County.
- A representative beneficiary served by the commission.
- A San Mateo County hospital staff physician.
- An HPSM contracted pharmacist.
- A member of the public at large.
Quality Improvement Projects
HPSM is required by California to conduct and/or participate in at least two Performance Improvement Projects (PIPs) annually. These projects may be based on HEDIS measures or other measures that have been identified by HPSM as opportunities for improvement.
The Center for Medicare and Medicaid Services (CMS) requires HPSM to conduct a Quality Improvement Project (QIP) yearly as well. CMS dictates that each QIP run for three consecutive years and consist of three phases: baseline assessment, intervention, and evaluation.
Even when QIPs focus on member activities, they cannot succeed without our provider network participation, so HPSM always appreciates provider input and feedback on the PIPs and QIPs. All projects are presented at the Quality Improvement and Health Equity Committee meetings, as well, to ensure that the tools and interventions planned appear feasible and useful from a provider perspective.
The QI Department works on a variety of topics including but not limited to the following:
- Blood Lead Screening.
- Cancer Screening.
- Chlamydia Screening.
- Comprehensive Diabetes Care.
- Controlling High Blood Pressure.
- Depression Screening
- Prenatal & Postpartum Care.
- Reducing Health Disparities.
- Reducing 30 Day Hospital Readmissions.
- Transitions of Care Management.
- Well Visits for Children and Adolescents.
Providers are encouraged to contact HPSM if they are currently working on any of these topics to discuss ways that HPSM can provide support for these efforts.
Facilitating health education intervention
If a member needs a health education service that is not outlined in the HPSM provider manual, the provider is encouraged to contact the Health Promotion Unit at 650-616-2165 for information about other community resources that may be available.
Medi-Cal and CareAdvantage Pay for Performance (P4P) Program
HPSM has a Pay for Performance programs for contracted Medi-Cal and CareAdvantage primary care providers. Additional program information can be found in the program guidelines on the HPSM website: https://www.hpsm.org/provider/value-based-payment
Potential Quality Issues (PQI)
HPSM has a Potential Quality Issue (PQI) Program that identifies deviations from provider performance, clinical care, and/or issues with outcome of care The reporting and processing of PQIs determines opportunities for improvement in the provisions of care and services to HPSM members. Appropriate actions for improvement are taken based on the PQI outcomes.
How are PQI’s Identified?
- Information gathered through concurrent, prospective, and retrospective utilization review.
- Referrals by health plan staff or providers.
- Facility site reviews.
- Claims and encounter data.
- Pharmacy utilization data.
- HEDIS medical record abstraction process.
- Medical/dental records audits.
- Phone log detail.
Scope of PQI reporting includes services provided by, but not limited to:
- Contracted providers including subcontractors that provide inpatient and outpatient services.
- Non-contracted providers.
- Durable medical equipment (DME) and medical supply providers.
- Pharmacy providers.
- Home health providers.
- Dental providers.
- Skilled nursing, long term care and rehabilitation facilities.
- Ancillary service providers including, but not limited to, laboratory, pharmacy, radiology, and ambulance.
PQIs may be reported for concerns relating to:
- Continuity of Care.
- Mental health.
- Pharmacy/Utilization Management Authorizations.
- Surgical Services.
Upon receipt of a PQI, medical records and/or initial provider responses are usually requested from the provider. Providers are expected and required to respond and provide supporting documentation [as requested] within the timeframe provided.
Following a comprehensive review of the PQI, if an HPSM Medical Director determines the presence of a quality of a care concern, a corrective action plan or other follow-up may be requested from the provider of concern. The provider of concern must institute the corrective action plan and provide a response within the timeframe provided.
Based on the severity or complexity of the case, the PQI can be referred to the Peer Review Committee (PRC) for additional review and determination.
Who can refer a PQI?
- HPSM staff.
- HPSM Members/Members of the community.
How can a PQI be referred?
Please use the PQI Referral Form. The form can be downloaded from the Provider Forms page on https://www.hpsm.org/provider/resources/potential-quality-issues. You can also request a copy of the form via email at firstname.lastname@example.org or by calling 650-616-5016. Complete forms can be returned by fax to 650-616-8235.