Compliance for Transplant Performance Centers Standardized Process
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
If a transplant program does not meet the Evaluation Process Standards criteria in the section below or is under investigation by Organ Procurement and Transplantation Network (OPTN), Centers for Medicare & Medicaid Services (CMS), or other industry-accepted oversight organizations, The Health Net Specialty Network Committee (SNC) determines whether the actions in the standard process are appropriate for the transplant program in question. Health Net requests all Transplant Performance Centers share any external oversight organization's findings and recommendations. Transplant Performance Centers that fail to submit this information or meet Health Net's defined evaluation criteria may be subject to removal from the network, per SNC discretion.
Letter of Deficiency
If a participating Transplant Performance Center does not comply with evaluation requirement (volume, graft survival, and/or patient survival outcomes), the following may apply:
- Health Net will send a letter of deficiency, and will indicate if a response is needed from the Transplant Performance Center.
- The Transplant Performance Center is given 21 days from the requested date to provide a response.
- If the Transplant Performance Center does not answer by the deadline, Health Net will mail a certified letter, giving a two-week extension.
- If the Transplant Performance Center does not answer after the second deadline, Health Net will send a third and final letter.
- This notice informs the Transplant Performance Center of SNC's decision, including possible termination of the Transplant Performance Center and corresponding transplant program due to non-response.
Corrective Action Plan Submission and Implementation
If the Transplant Performance Center is non-compliant for the transplant volume and/or survival criteria, they may be subject to completing a corrective action plan (CAP). If requested, the Transplant Performance Center must submit the CAP within 21 calendar days of the requested date. Health Net reviews the CAP for appropriateness and completeness, notifying the Transplant Performance Center if the CAP is approved or more information is needed. If Health Net does not approve the CAP, the Transplant Performance Center is notified and granted an additional 15 calendar days for revision and subsequent resubmission of their CAP to Health Net.
Health Net will send a second notice of deficiency to Transplant Performance Centers that have not responded to the first notice of deficiency. The Transplant Performance Center will have an additional 15 days from the date of receipt to respond to the originally requested CAP. Health Net reviews Transplant Performance Centers that do not respond to the second letter of deficiency for recommendations or sanctions, which may include suspending new patient referrals.
Health Net sends a third and final notice to the Transplant Performance Center if a response to requests for a CAP have not been provided, or if there is insufficient progress toward correcting the deficiencies. Such notice informs the Transplant Performance Center of Health Net's decision, including potential termination of the transplant program and that these actions may be avoided if both of the following occur:
- The Transplant Performance Center submits an acceptable CAP to Health Net within 15 calendar days of receipt of the final notice.
- The Transplant Performance Center completes and demonstrates substantial progress toward completing the correction within 30 calendar days.
Once a CAP has been approved, the Transplant Performance Center program must report updates at six months and one year following the original CAP submission date, or until completion of the CAP implementation.
On-Site Visits
At any time, either Health Net or a Transplant Performance Center may request, with reasonable advance notice, a meeting to discuss transplant program issues or concerns. Either party may not unreasonably withhold such meeting requests.
Health Net's Specialty Network Committee is responsible for monitoring and making recommendations for appropriate action regarding Health Net's various performance center networks, including the Transplant Performance Centers. Under the direction of the SNC, Health Net trends and analyzes performance data annually for each contracted Transplant Performance Center program at least every 12 months, or as new information becomes available. The standardized review process monitors and evaluates the quality and outcomes of Transplant Performance Centers to ensure our members have access to high-quality and safe surgical care. Data analysis is based upon existing industry-accepted sources, such as the following for transplant programs: the Organ Procurement Transplant Network [OPTN-administered by the United Network for Organ Sharing (UNOS)], the Scientific Registry of Transplant Recipients (SRTR), and the National Marrow Donor Program). If unavailable via the publicly reported sources, Health Net will request additional data directly from contracted programs.
Health Net may conduct off-cycle reviews of Transplant Performance Centers that do not meet the evaluation criteria, or if under investigation by OPTN, CMS, or other industry-accepted oversight organizations. Health Net SNC will determine whether the actions in the standard process are appropriate for the Transplant Performance Center program in question. Health Net requests all Transplant Performance Centers share any external oversight organization's findings and recommendations. Transplant Performance Centers that fail to submit this information or meet Health Net's defined evaluation criteria may be subject to removal from the network, per SNC discretion.
Volume Criteria
The minimum volume criteria required by adult-specific Transplant Performance Center programs is maintained. A combined volume is calculated for Transplant Performance Centers that contract for both adult and pediatric populations.
Type |
Required per year |
|---|---|
Bone marrow - Allograft |
10 or more transplants |
Bone marrow - Autologous |
10 or more transplants |
Heart |
10 or more transplants |
Intestine |
10 or more transplants |
Kidney |
30 or more transplants |
Liver |
10 or more transplants |
Lung |
10 or more transplants |
Pancreas |
Center must meet kidney volume criteria of 30 or more |
Heart-Lung |
Center must meet volume criteria for both heart (10) and lung (10) |
Kidney-Pancreas |
Center must meet kidney volume criteria of 30 or more |
Volume data reported by SRTR, NMDP, BMT InfoNet, and OPTN is reviewed yearly. Health Net will request volume data directly from the Transplant Performance Centers yearly when not available via publicly reported sources.
Graft and Patient Survival Criteria for Organ Transplants
SRTR collects graft and patient survival data and reports one year after a transplant is completed. Methods for data collection and analysis are defined by the SRTR in the Technical Methods Guide to the Center-Specific Reports posted on https://www.srtr.org/. SRTR calculates statistics for thoracic and non-thoracic organs, based on transplant data accrued over a 30-month period. SRTR updates these reports every six months, which is the standard reporting period.
Health Net's graft and patient survival criteria aligns with the Organ Procurement and Transplantation Network (OPTN) and Membership and Professional Standards Committee's (MPSC) criteria.
Health Net's Graft and Patient Survival Criteria are:
For centers with volume greater than 10 transplants per year:
- The probability that the hazard ratio (HR) exceeds 1.20 is greater than 0.75 (75%); and/or
- The probability that the hazard ratio (HR) exceeds 2.50 is greater than 0.10 (10%).
For centers with small volume (less than 10 transplants per year):
- The number of observed events is greater than one and the number of transplants is less than 10.
Health Net reviews findings as documented through Specialty Network Committee (SNC) assessments and receives SNC recommendations to determine appropriate actions based on findings. Appropriate Health Net Regional Medical Directors and Health Net Provider Network Managers are consulted before actions are determined. For Transplant Performance Centers that consistently fall below criteria, Health Net will monitor and determine corrective actions, as appropriate.