PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY / PROCEDURE
Policy/Procedure Number: MP PR 202
Lead Department: Provider Relations
Policy/Procedure Title: Monitoring of PHC Specialist Physician
External Policy
Network Availability and Accessibility Policy & Procedure
Internal Policy
Next Review Date: 09/14/2016
Original Date: 08/12/1998
Last Review Date: 09/09/2015
Applies to:
Medi-Cal
Healthy Kids
Employees
Reviewing
Entities:
IQI
P&T
QUAC
OPERATIONS
EXECUTIVE
COMPLIANCE
DEPARTMENT
Approving
Entities:
BOARD
COMPLIANCE
FINANCE
PAC
CEO
COO
CREDENTIALING
Approval Signature: Robert Moore, MD, MPH
DEPT. DIRECTOR/OFFICER
Approval Date: 09/09/2015
I.
RELATED POLICIES:
A. MPQP1023
II.
IMPACTED DEPTS:
A. Provider Relations
III.
DEFINITIONS:
A. N/A
IV.
ATTACHMENTS:
A. N/A
V.
PURPOSE:
To provide and monitor adequate availability and accessibility to Contracted Specialist Physicians for
Partnership HealthPlan of California (PHC) members.
VI.
POLICY / PROCEDURE:
The HealthPlan is responsible for evaluating the availability and accessibility of Specialist Physicians
network.
A. The Standard as defined by PHC for Availability:
1. High Volume Key Specialist Physician is available within 50 miles of member's residence.
2. High volume specialty services are identified through PHC claims data. A claim data report is
generated by the PHC Claims Department on an annual basis and evaluated to identify non-hospital
based, high volume specialties. The top ten (10) specialties are identified by the highest number of
unique member claims.
3. PHC takes into consideration the special cultural and linguistic needs of its members.
4. The HealthPlan will conduct a GeoAccess® analysis of non-hospital based high volume specialties
to monitor the standard of one specialist within 50 miles of member's residence.
5. Per DHCS, the Plan will ensure full time equivalent Physician to member ratio is 1:1200 members
per DHCS contract requirements.
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Policy/Procedure Number: MP PR 202
Lead Department: Provider Relations
Policy/Procedure Title: Monitoring of PHC Specialist Physician ☐External Policy
Network Availability and Accessibility Policy & Procedure
☐Internal Policy
Next Review Date: 09/14/2016
Original Date: 08/12/1998
Last Review Date: 09/09/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
B. Plan Standards for accessibility of Specialty Services are defined in policy MPQP1023; Access
Standards.
1. PHC commits to contract with specialist providers the meet PHC criteria in geographic areas served
by the Plan.
2. The Plan utilizes a variety of methods to increase access to specialty services which include, but are
not limited to: telemedicine, telephone consults, and web-based e-consults.
3. Note:
Specialist Physicians are allowed to freely communicate with patients regarding their health status,
medical care and treatment options, alternative treatment, and medication treatment regardless of
benefit coverage limitations. Patients must be informed of risks, benefits and consequences of the
treatment options. Patients will be allowed to refuse treatment and make decisions about ongoing
and future medical treatments. Physicians must provide information regarding treatment options,
including the option of no treatment in a culturally competent manner. Health care professionals
must ensure that patients with disabilities have effective communication through out the health
system in making decisions regarding treatment options.
4. The Provider Relations Department is responsible for monitoring accessibility to specialty care.
Using the high volume claims data, the top 10 specialties identified by the highest number unique
member claims, are surveyed by using one or more of the following methods:
a.
A telephone survey of the physicians' office, asking for specific appointment time to be
scheduled, and/or 3rd next available appointment.
b. A “secret shopper” survey.
c.
On-site evaluation of physicians appointment scheduling system.
d. Interviews with office staff.
5. After hours care is monitored by the Provider Relations Department by placing a call to the
physicians office after the close of business day and document the findings.
a.
Telephone wait times are monitored by calling the practice phone number, findings are
documented.
b. Member appointment wait times are evaluated by telephone and/or site review.
6. Reports and Corrective Action Plans (CAP) will be presented to the Chief Medical Officer and
Regional Medical Directors for review, recommendation, and approval. The Provider Relations
Department is responsible for implementation and monitoring of the CAP. The goal is to assist
providers and remeasure to ensure standard met.
Accessibility to specialty care is continuously monitored through member complaints, member focus
groups, QI activities, provider focus groups, and provider input.
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Policy/Procedure Number: MP PR 202
Lead Department: Provider Relations
Policy/Procedure Title: Monitoring of PHC Specialist Physician ☐External Policy
Network Availability and Accessibility Policy & Procedure
☐Internal Policy
Next Review Date: 09/14/2016
Original Date: 08/12/1998
Last Review Date: 09/09/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
When issues are identified through member complaints, the Provider Relations department takes
immediate action and addresses the issues with the specialist office.
C. Reporting and Actions
1. The Provider Relations Department issues a report documenting the findings.
2. The final report is forwarded to the IQI for review, recommendations, and approval.
3. The PHC Provider Relations Department is responsible for implementation, monitoring and
subsequent reporting of the Corrective Action Plan.
4. When a practitioner terminates a contract with PHC, the member is allowed to receive ongoing care
with the practitioner for up to 60 days to treat an illness and through the postpartum period for
deliveries as long as the provider agrees to the Plan's rate of reimbursement.
D. Ongoing Monitoring of Specialist Network
1. PHC carefully monitors the Specialist provider network. Terminated providers are reviewed
monthly to identify potential deficiencies. Member complaints, appeals and grievances regarding
access and availability to provider services are monitored via the member grievance process.
2. PHC conducts periodic member satisfaction surveys that include questions about access to specialty
care.
3. The Plan's Specialty Access Workgroup activities are included in the ongoing monitoring of the
PHC network.
4. Feedback from the provider network is another means by which PHC monitors access to services.
When issues are identified the Provider Relations department takes immediate action to address
deficiencies.
VII.
REFERENCES:
A. DHCS
B. DMHC
VIII.
DISTRIBUTION:
A. PHC Provider Manual
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:
Provider Relations Director
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Policy/Procedure Number: MP PR 202
Lead Department: Provider Relations
Policy/Procedure Title: Monitoring of PHC Specialist Physician ☐External Policy
Network Availability and Accessibility Policy & Procedure
☐Internal Policy
Next Review Date: 09/14/2016
Original Date: 08/12/1998
Last Review Date: 09/09/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
X.
REVISION DATES:
Medi-Cal
02/15/00, 03/01/00, 04/19/00, 04/18/01, 08/15/01, 04/17/02, 05/21/03, 06/16/04, 05/18/05, 06/15/05,
06/21/06, 05/16/07, 07/16/08, 03/18/09, 03/17/10, 03/16/11, 03/21/12, 08/15/12, 08/14/13, 09/10/14
Healthy Kids
06/21/06, 05/16/07, 07/16/08, 03/18/09, 03/17/10, 03/16/11, 03/21/12, 08/15/12, 08/14/13, 09/10/14,
09/09/2015,
PREVIOUSLY APPLIED TO:
PartnershipAdvantage:
MP PR #202 - 06/2006 to 01/01/2015
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