Medical Mutual - Health Plans for Life

Quality Improvement Program

Medical Mutual's mission is to build a company that meets the needs of our policyholders, customers and communities. To support this mission, Medical Mutual's Care Management department has implemented a comprehensive Quality Improvement (QI) Program and continually redesigns this program to:

  • Improve the quality of healthcare services for members and their access to those services
  • Communicate clinical information to members and providers
  • Monitor and evaluate the quality and safety of healthcare provided to members
  • Achieve and maintain formal accreditation
Quality Improvement Program Publications

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Quality Improvement Program Activities

To learn more about specific QI Program Activities developed by Medical Mutual, please select a topic from the list below.

Member and Provider

Member

Provider

Member and Provider

Accessibility Standards

Medical Mutual's goal is to ensure that each member has timely access to provider treatment. Standards have been established for network primary care physicians (PCPs), specialists, and behavioral health professionals.

These standards are published annually in provider and member newsletters, provider directories and posted on this website. Compliance with accessibility standards is monitored via audits and HEDIS member satisfaction surveys. In addition, QI Analysts review member complaints regarding access and implement provider corrective action plans (CAPs) as indicated.

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Care Management Department

Utilization management (UM), case management and disease management activities comprise a comprehensive care management program, and are integrated with clinical quality improvement activities. All Care Management and quality improvement activities report through the same committee structure, and all staff ultimately report to the Chief Medical Officer for clinical issues and the Vice President of Care Management for all administrative issues.

UM activities within care management include prior approval, concurrent review, retrospective review, discharge planning, chart audit and medical claims review for medical/surgical and mental health/substance abuse services.

Case management is a multidisciplinary process and involves the coordination of complex care needs while facilitating flexible, individualized plans of care and utilizing community resources. This process is a collaborative effort between the member, family, physician and other members of the healthcare delivery team. The case management process provides cost-effective options for selected members with complex medical and social needs.

Disease management activities include identification of eligible members, completion of needs assessments, determination of the appropriateness of services, formulation of an individualized plan of care, implementation of services, measurement and evaluation of the plan of care, and a program evaluation. Our Company offers disease management and maternity programs to assist members with a chronic disease or pregnancy.

Reports focused on care management activities are generated on a routine basis and are utilized to assess the effectiveness, appropriateness and efficiency of the care management program.

Contact the Care Management Department.

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Clinical Care and Service Studies

Each year Medical Mutual identifies clinical and service concerns/topics for focused studies and/or interventions. Selection of topics is made with substantial input from the Clinical Quality Improvement (CQI) and the Service Quality Improvement Committees. A variety of sources are utilized to identify topics, including Healthy People 2010, Healthy Children 2010, Healthcare Effectiveness Data and Information Set (HEDIS), care cost analysis, member demographics analysis, claims data analysis, medical record reviews, provider and member surveys and referrals of potential quality issues from Medical Mutual staff and committees. The objective in identifying topics is to ensure they represent and address the needs of the member population. Topics may address the total population or specific segments of members (i.e., women of childbearing years, asthmatic members, etc.).

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Educational Communications

Medical Mutual continues to channel its efforts towards the educational component of quality improvement. Providers receive information via the Provider Manual and newsletters. Members receive newsletters, direct mailings, and their certificate of coverage.

Medical Mutual's Clinical Quality Improvement Department may be contacted at 800.586.4523

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Preventive Care Service

Clinical preventive care service is an essential aspect of medical practice today. To promote the delivery of regular preventive care services by physicians and utilization of such services by members, Medical Mutual annually reviews preventive care guidelines. The guidelines are developed and updated by the Clinical Quality Improvement Department and participating network physicians biennially, or when appropriate. Currently, prenatal, pediatric and adult guidelines exist. The guidelines are considered minimum standards which all Primary Care Physicians (PCPs) are expected to meet when providing routine medical care to members.

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Members

Appropriate Care

To ensure all members receive the most appropriate medical care available, Medical Mutual has a team of people who review certain treatments, tests or hospital stays in a process called “utilization management”. Medical Mutual distributes an appropriate care statement to all employees, contracted physicians and management staff who deal with utilization management activities stating the following:

  • Utilization management decisions are based only on the appropriate use of care and services for the member and existence of coverage.
  • Medical Mutual does not directly or indirectly reward or incent providers or any other individuals participating in utilization management decisions for denying or limiting coverage or service.
  • Medical Mutual does not provide financial incentives for utilization management decisions that result in the underutilization of care or service.
  • Decisions regarding hiring, compensation, termination, promotion or other related matters with respect to any individual are not made based on the probability that the individual will support a denial of coverage.
  • In addition, they: (1) do not participate in underwriting activities; (2) are not involved in determining or advancing Corporate profitability; and (3) their activities are not monitored or directly controlled by anyone with such authority or responsibility.

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Company-wide Member Appeals Monitoring

Medical Mutual has a formal process for members which advises them of their right to file an appeal and provides timeframes for appeal resolution. Members are informed of their rights through their certificate of coverage, medical determination letters, EOB (Explanation of Benefits), and member newsletters. Members are also notified of their rights when they contact the Customer Service department with a grievance about a denied claim or service. Grievances are tracked for timeliness and trended to identify potential issues for quality improvement intervention.

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Safety Monitoring and Activities

Medical Mutual's Quality Improvement Program Description provides a detailed description of each of the safety topics listed below:

  • Inpatient Mortality Reports
  • Hospital Incurred Injuries/Adverse Occurrence Tracking
  • Prescription Medication Monitoring
  • Ongoing Review of Potential Quality of Care Issues
  • Office Safety Review
  • Communication with Providers and Members
  • Focused Studies on Member Safety

Following the release of the 1999 Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System, a coalition of employers formed The Leapfrog Group. Leapfrog's goal is to improve the safety of hospitalized patients through the implementation of three initiatives: computerized physician order entry (CPOE), evidence-based hospital referral and Intensive Care Unit (ICU) physician staffing. Details of the Leapfrog initiatives are available on their website at www.leapfroggroup.org.

The website also offers a survey that hospitals may complete to report their progress toward meeting the Leapfrog safety standards.

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Satisfaction Measurement and Improvement

Maintaining high levels of member satisfaction is a primary goal of the Quality Improvement Program. Objectives of member satisfaction activities are to:

  • Provide members with opportunities to express their opinions about Medical Mutual products and service.
  • Share member perceptions with providers to encourage performance improvements.
  • Utilize member input to identify potential areas for quality improvement action.

Vehicles utilized to achieve the above objectives include:

  • Member satisfaction surveys, including general surveys and surveys focused on specific products, populations, or concerns
  • Analysis of member complaints and appeals.
  • Analysis of members' requests to change providers.
  • Monitoring telephone service and implementing corrective action plans to achieve optimum results regarding the following service parameters:
    • Incoming calls per day
    • Wait time to reach a service representative
    • Calls connected (caller remains on the line)
    • Time required to access customer's claims history
    • Number of inquiries resolved on initial contact
    • Turnaround time for inquiries unresolved on initial contact

Medical Mutual tracks member complaints for timeliness and trends the complaints to identify potential issues for quality improvement intervention.

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Provider

Affirmative Statement

Medical Mutual is committed to ensuring the appropriate utilization of care and service provided to all members. To ensure this commitment, Medical Mutual has asked all employees, consultants, and management staff involved in utilization management decisions to sign an affirmation statement that affirms their understanding of the following:

  • Utilization management decisions are based only on the appropriate use of care and services for the member.
  • Medical Mutual does not directly or indirectly reward or incent providers or any other individuals participating in utilization management decisions for denying or limiting coverage or service.
  • Medical Mutual does not provide financial incentives for utilization management decisions that result in the underutilization of care or service.

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Practice Guidelines

To promote the provision of quality healthcare services and the management of selected conditions and chronic diseases, Medical Mutual develops and disseminates practice guidelines to providers for input and adoption. Such guidelines are based upon, but not limited to, guidelines from the American Medical Association (AMA), the American Psychiatric Association (APA), the American College of Obstetrics and Gynecology (ACOG) and other specialty physician boards and colleges. Practice guidelines are reviewed at least every two years and updated as necessary to reflect changes in medical practice.

Medical Mutual monitors physician compliance with published guidelines via periodic medical record review and claims data analysis. Results of monitoring activity are analyzed and used to develop and implement interventions for the education of providers regarding Medical Mutual guidelines.

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Network Availability Measurement and Improvement

To ensure that network providers and hospitals are available to members, Medical Mutual has established standards for the following:

  • Appropriate ratios of PCPs and specialists to members
  • Geographic location and travel time to providers/hospitals

Medical Mutual seeks to maintain a comprehensive practitioner network available for its members. Medical Mutual defines specific goals in comparison to the total available practitioner population and geographic availability across practitioner specialties. In addition, Medical Mutual monitors member complaints and member satisfaction regarding provider network availability across practitioner specialties as well as cultural and/or linguistic needs. With these goals, members will have sufficient practitioner alternatives available to meet their medical needs. Once goals are attained in a region, recruiting efforts are terminated and resources are focused on improving practitioner availability in deficient areas.

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Network Clinical and Service Issues

The QI Program is responsible for identifying potential clinical and service issues, investigating potential causes and solutions, taking action to improve performance and evaluating the effectiveness of these actions.

Personnel from the following operational areas are primary sources for identifying possible concerns regarding quality of care and service:

  • Benefit Administration
  • Care Management
  • Claims/Member Services
  • Clinical Credentialing
  • Clinical Quality Improvement
  • Marketing
  • Network Management
  • Professional Contracting

Cases with potential clinical or service issues are logged into either the Contact Online Reporting System (CORS) or the PReview Managed Care System and investigated. Clinical issues are referred to the CQI Department for review and may result in review by the Chief Medical Officer and/or the CQI Committee.

In cases where provider performance issues are noted and improvements are not achieved within reasonable time frames, Medical Mutual has instituted a provider termination process. The policies and procedures on termination include a formal provider appeal process where appropriate.

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Satisfaction Measurement and Improvement

Maintaining high levels of provider satisfaction is another goal of the QI Program. Objectives of provider satisfaction activities are to:

  • Afford providers the opportunity to express their opinions about Medical Mutual policies and procedures regarding claims payment, the Care Management process, and various administrative components of the managed care products.
  • Share provider perceptions with internal Medical Mutual departments to encourage performance improvements.
  • Utilize provider input to identify potential areas for quality improvement action.

Vehicles utilized to achieve the above objectives include:

  • Provider satisfaction surveys.
  • Analysis of provider comments in response to the distribution of guidelines, newsletters, and other communications.

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