QUALITY IMPROVEMENT PROGRAM
The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage organizations to have an ongoing Quality Improvement (QI) program to ensure health plans have the necessary infrastructure to coordinate care, promote quality, performance, and efficiency on an ongoing basis. The requirements for the QI program are based in regulation at 42 CFR§ 422.152.
Cigna-HealthSpring’s QI program is dedicated to improving the health of the community we serve by delivering the highest quality and greatest value in health care benefits and services.
- Integrity – We always conduct ourselves in a professional and ethical manner
- Respect – We all have value and will treat others with dignity and respect
- Team – We recognize that employees are our main asset and encourage their continued development
- Communications – We encourage the free exchange of thoughts and ideas
- Balance – We manage both our personal and company priorities
- Excellence – We continuously strive to exceed our customers’ expectations
- Prudence – We always use the company’s financial resources wisely
Cigna-HealthSpring shall apply the guiding values described above to its oversight and operation of its system and:
- Provide services that are clinically driven, cost effective and outcome oriented
- Provide services that are culturally informed, sensitive and responsive
- Provide services that enable customers to live in the least restrictive, most integrated community setting appropriate to meet their health care needs
- Ensure that guidelines and criteria are based on professional standards and evidence- based practices that are adapted to account for regional, rural and urban differences
- Foster an environment of quality of care and service within Cigna-HealthSpring, the Senior Segment of Cigna and through our provider partners
- Promote customer safety as an over-riding consideration in decision-making
The Quality Improvement program provides guidance for the management and coordination of all quality improvement and quality management activities throughout the Cigna-HealthSpring organization, its affiliates, and delegated entities.
The program describes the processes and resources to continuously monitor, evaluate and improve the clinical care and services provided to enrollees for both their physical and behavioral health. The program also defines the health plan’s methodology for identifying improvement opportunities and for developing and implementing initiatives to impact opportunities identified.
The scope of the program includes:
- All aspects of physical and behavioral care including accessibility, availability, level of care, continuity, appropriateness, timeliness and clinical effectiveness of care and services provided through Cigna-HealthSpring and contracted providers and organization
- All aspects of provider performance relating to access to care, quality of care including provider credentialing, confidentiality, medical record keeping and fiscal and billing activities
- All covered services
- •All professional and institutional care in all settings including hospitals, skilled nursing facilities, outpatient and home health
- All providers and any delegated or subcontracted providers
- Management of behavioral health care and substance abuse care and services
- Aspects of Cigna-HealthSpring internal administrative processes which are related to service and quality of care including credentialing, quality improvement, pharmacy, health education, health risk assessments, Clinical Practice Guidelines, Utilization Management, customer safety, case management, disease management, special needs, complaints, grievances and Appeals, customer service, provider network, provider education, medical records, customer outreach, claims payment and information systems.
Quality Management Program Goals
The primary objective of the Quality Improvement program is to promote and build quality into the organizational structure and processes to meet the organization’s mission of improving the health of the community we serve by delivering the highest quality and greatest value in health care benefits and services. The goals the organization has established to meet this objective are:
- Maintain an effective quality committee structure that:
- Fosters communication across the enterprise
- Collaboratively works towards achievement of established goals
- Monitors progress of improvement efforts to established goals; and
- Provides the necessary oversight and leadership reporting
- Ensure patient care and service is provided according to established goals and metrics
- Ensure identification and analysis of opportunities for improvement with implementation of actions and follow-up as needed
- Promote consistency in quality program activities
- Ensure the QI program is sufficiently organizationally separate from the fiscal and administrative management to ensure that fiscal and administrative management does not unduly influence decision-making regarding organizational determinations and/or Appeals of adverse determinations of covered benefits
- Ensure timely access to and availability of safe and appropriate physical and behavioral health services for the population served by Cigna-HealthSpring
- Ensure services are provided by qualified individuals and organizations including those with the qualifications and experience appropriate to service customers with special needs
- Promote the use of evidence-based practices and care guidelines
- Improve the ability of all Cigna-HealthSpring staff to apply quality methodology through a program of education, training, and mentoring
- Establish a rigorous delegation oversight process
- Ensure adequate infrastructure and resources to support the Quality Improvement program.
- Ensure provider involvement in maintaining and improving the health of Cigna-HealthSpring customers, through a comprehensive provider partnership