- Participating Physician Groups (PPG)
Health Net measures, monitors and oversees provider compliance and requires corrective actions when deficiencies are verified. Delegation may be revoked and the provider's contract terminated if the corrective action process does not resolve the deficiency.
In addition to routine data collection, monitoring, evaluation, and analysis, the Health Net staff is available to assist providers with:
- Alerting the delegated entity regarding possible areas of non-compliance
- Furnishing information regarding regulations
- Developing corrective action plans (CAPs)
- Sharing best practices
- Offering guidance regarding on-site review by outside agencies
Delegation Oversight Committee
The Health Net Delegation Oversight Department is under the direction of the Senior Vice President of Operations. The Delegation Oversight Committee (DOC) is chaired by the Vice President of Delegation Oversight . The committee meets bi-monthly and is comprised of but not limited to senior management representatives from the Health Net Provider Network Management, QI, Health Care Services, Medical Management, Provider Services, Member Services, Actuarial, Appeals and Grievances (A&G), Claims, Encounters, Credentialing, Delegation Oversight, Program Accreditation, and Finance departments. The committee reviews monthly compliance reports and hears recommendations from the Delegation Oversight Workgroup (DOW) and other departments regarding provider compliance deficiencies. The committee collaboratively makes decisions to remedy noncompliance as quickly as possible. Those actions may include closer monitoring by the oversight staff, developing CAPs, escalating to Joint Operations Committees revoking delegation of specific functions, imposing progressive sanctions (such as freezing enrollment and financial sanctions), and when necessary, notifying providers of contract breaches and contract termination.
Credentialing and Recredentialing
Failure to meet compliance with Health Net standards for credentialing and recredentialing is reported to the Health Net DOC for review and discussion if actions to resolve deficiencies and may result in revocation of delegation status.
Participating physician groups (PPGs) are required to measure and report data elements necessary to determine compliance with Healthcare Effectiveness Data and Information Set (HEDIS) quality benchmarks.
Member Complaints, Appeals and Grievances
The Health Net Member Services or Appeals and Grievances Departments work to resolve individual member complaints. All member complaints and inquiries are entered into a database for tracking, and reports are generated quarterly to allow for tracking and profiling within and between providers. The quarterly complaint report aggregates the type of complaint by PPG and by region. Health Net's Credentialing Committee, regional medical directors (RMDs), the Delegation Oversight director, and QI staff reviews the reports. A CAP is implemented, if necessary, and tracking and follow-up evaluations continue to monitor the success of the action plan.
Member complaints with potential quality of care issues are forwarded to the Health Net Clinical Appeals and Grievances Department, which conducts an investigation of each issue and tracks trends for quality of care issues by provider, PPG and type of issue. Provider-specific cases are prepared and presented to the Health Net Peer Review Committee for review and action. During the investigation of potential quality of care issues, the QI specialist may request information, medical records or implementation of provider-specific action plans from the PPG. Noncompliance with these requests may lead to sanctions, such as freezing enrollment of Health Net members until the issue is resolved or possible termination of the Health Net contract.
Preventive Care Guidelines
Health Net provides feedback to PPGs on their preventive care services in an effort to encourage delivery of such services. Techniques include quality of care and service report cards, discussions at physician forums, onsite meetings with PPG staff, and financial incentives to increase the amount of preventive care services. Member education is also part of this effort.
Health Net requires that PPGs and participating primary care physicians (PCPs) follow the clinical practice guidelines recommended by the United States Preventive Services Task Force (USPSTF), the American Congress of Obstetrics and Gynecology (ACOG), the American Cancer Society (ACS), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) in the treatment of Health Net members. A Health Net member's medical history and physical examination may indicate that further medical tests are needed. As always, the judgment of the treating physician is the final determinant of member care.
Refer to the preventive care guidelines discussion under the Benefits topic for more information.
Notice to Change PPA
If a participating provider needs to request a change to the information currently in their Health Net Provider Participation Agreement (PPA), the request must be made in writing. The request can be made in one of the following ways:
- Certified U.S. mail with a return receipt requested, postage prepaid
- Overnight courier
The request should be sent to Health Net's main corporate address.