2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Home Healththe management of decubitus ulcers for the Agencyfor Healthcare Policy and Research).Data collected by agencies from required reportingand from PHHSN prior authorization analysis willbe used to generate the quality and utilizationsummaries. The utilization and quality managementprogram will be overseen by the quality subcommitteeof the PHHSN. This committee will actas a utilization and quality committee that isresponsible for providing oversight, review, andrecommendations regarding home care practicerelative to utilization benchmarks, credentialing,grievances, and recommendations forimprovements.If a need for improvement is identified for anagency, PHHSN will work with the agency toidentify the root cause and develop a correctiveaction plan. Periodic follow-up reporting will bedone by PHHSN.Outcome measurement will be monitored as itrelates to utilization management. Quarterly andannual reporting of measurements will beconducted through the Presbyterian HomeHealthcare Albuquerque Professional AdvisoryBoard, which will consist of physicians, clinicians,Presbyterian representatives and the PHHSNdirector. The measurements that will be reviewedare as follows:Individual agency’s random annual chart auditresultsPatient satisfaction survey resultsUtilization reports relative to unduplicatedcensus, admits, and visits, which will bebenchmarkedAgency satisfaction with PHHSN surveyresultsDenials/appeals related to medical necessityGrievances and complaints as received byPresbyterian, including disagreement with thedischarge date of service by the care recipientor their authorized representativeReporting RequirementsReporting of statistical data by agencies to PHHSNis required toEffectively identify issues and trends byagenciesComplete root-cause analysis of the trendsSupport the development of an action plan bythe agency to enhance or modify acceptedpractice methodologiesRe-evaluate the data following implementationof changes (to note changes in trends)Reports must be sent to PHHSN within theidentified time frames. Results will be sent out inthe PHHSN newsletter. Each agency must providePHHSN random concurrent review self-audits on ayearly basis.Each agency must complete a monthly audit on allPresbyterian MediCare PPO members to ensurethat the Medicare Notice of Non-Coverage wasprovided to members in accordance with Medicareregulation. The audit results are sent to PHHSNmonthly.11-92014 Practitioner and Provider Manual - Ver. 3