Overview
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
The Health Net Quality Improvement (QI) program includes the development and implementation of standards for clinical care and service, the measurement of compliance to the standards and implementation of actions to improve performance. The scope of these activities considers the enrolled populations' demographics and health risk characteristics, as well as current national, state and regional public health goals. Health Net’s Population Health Management strategy provides usage risk stratification data compiled from a variety of data sources to help teams target the right members with the right resources to address member health and social determinants of health (needs at all stages of life. The QI program impacts the following:
- Health Net members in all demographic groups and in all service areas in which Health Net is licensed.
- Network Providers, including physicians, facilities, hospitals, ancillary providers, and any other contracted or subcontracted provider types.
- Aspects of Care, including level of care, health promotion, wellness, chronic conditions management, care management, continuity of care, appropriateness, timeliness, and clinical effectiveness of care and services covered by Health Net.
- Health Disparities by supporting activities and initiatives that improve the delivery of health care services, patient outcomes, and reduce health inequities.
- Communication to meet the cultural and linguistic needs of all members.
- Behavioral Health Aspects of Care integration by monitoring and evaluating the care and service provided to improve behavioral health care in coordination with other medical conditions.
- Provider/Provider Performance relating to professional licensing, accessibility and availability of care, quality and safety of care and service, including practitioner and office associate behavior, medical record keeping practices, environmental safety and health, and health promotion.
- Services Covered by Health Net, including preventive care; primary care; specialty care; telehealth, ancillary care; emergency services; behavioral health services; diagnostic services; pharmaceutical services; skilled nursing care; home health care; Health Homes Program (HHP), long term care (LTC), Long-Term Services and Supports (LTSS): Community Based Adult Services (CBAS), and Multipurpose Senior Services Program (MSSP) that meets the special, cultural and linguistic, complex or chronic needs of all members.
- Internal Administrative Processes which are related to service and quality of care, including customer service, enrollment services, provider relations, practitioner and provider qualifications and selection, confidential handling of medical records and information, case management services, utilization review activities, preventive services, health education, information services, and quality improvement.
Health Net does not delegate its QI program or oversight responsibilities to PPGs, participating providers, hospitals, or ancillary providers. PPGs, participating providers, hospitals, and ancillary providers are required to comply with the standards and requirements set forth by Health Net, included in this operations manual.
Health Net regularly communicates information about Health Net's QI program goals, processes and outcomes as they relate to member care through provider updates, committee meetings and other forums. QI program information is also available to providers by request through Health Net's Provider Services Center (Commercial, Medicare Advantage, Medi-Cal, CalViva Health, Community Health Plan of Imperial Valley).