How our provider monitoring program protects member care
Every day, our members trust us to connect them with quality health care providers. But how do we ensure that every provider and facility in our network meets the highest standards? The answer lies in our comprehensive provider monitoring program. This program is critical in ensuring network quality and safety.
Quality health care starts with qualified providers. Our credentialing program ensures that all practitioners and organizations in our network adhere to rigorous standards set by the Arizona Health Care Cost Containment System (AHCCCS), the National Committee for Quality Assurance (NCQA) and State and Federal regulations. This isn't just a checkbox exercise; it's a critical safeguard that protects our members and maintains the integrity of our network.
A thorough verification process for every provider joining our network is required and is done so working with the Arizona Credentialing Alliance (AzAHP). However, our commitment doesn't stop there. Every 36 months, we re-credential each practitioner, incorporating real-world performance data including Quality of Care (QOC) metrics, Grievance and Appeals (G&A) information and utilization patterns. This ongoing cycle ensures that providers continue to meet our standards throughout their time in our network.
Sometimes, you need to see it to believe it. Our onsite quality team responds to members’ concerns about physical accessibility, facility appearance, equipment adequacy, member autonomy and Best Practice record-keeping. When issues arise, we don't just take notes, we conduct on-site visits to assess conditions firsthand. If deficiencies are identified, we work with providers to implement a Corrective Action Plan (CAP), to ensure that problems are resolved and standards are met.
We work hard to partner with our providers, meeting them where they are and supporting their success every step of the way. This often means dedicating many hours to hands on technical assistance to help strengthen processes, improve performance and navigate complex requirements together. Our commitment to accountability also extends further into our organization with rigorous oversight and accountability for all QM annual audits, with results reported bi-monthly to our Quality Management/Performance Improvement (QM/PI) Committee. This ensures that our partners uphold the same high standards we require of ourselves.
The bottom line is that provider monitoring isn't just a department, it's a promise. A promise that every provider in our network has been thoroughly vetted, continuously monitored and held accountable to the highest standards. It's how we transform regulatory requirements into real world quality and safety for our members.
For any questions related to our provider monitoring, please reach out to [email protected].