Medicare - Compliance, Termination & Appeals |
Compliance (Practitioners & HDOs)
Practitioner Compliance
ConnectiCare and its contracted provider organizations have had compliance standards in accordance with ConnectiCare policy since September 1994. Physicians should be aware that lack of compliance with pre-authorization procedures, unauthorized referrals to out-of-plan providers, or noncompliance with ConnectiCare policies may cause significant problems for health plan members. ConnectiCare looks to its physician network to minimize these problems and promote efficient health plan operations.
ConnectiCare's Health Services Department will work with contracted practitioners and provider organizations to uphold these standards. When a provider is not compliant in one of the categories below, and/or per the applicable provider agreement, disciplinary action, including but not limited to termination of the agreement, may be initiated in accordance with ConnectiCare policy and the provider agreement. Some of the reasons for disciplinary actions may include:
• Lack of compliance with pre-authorization policy and procedures
• Unauthorized out-of-plan referrals
• Inappropriate billing of members
• Lack of cooperation with case management or Credentialing & Recredentialing Department processes.
Examples:
• Refusal to share information when asked to clarify/substantiate medical necessity for continued hospitalization.
• Refusal to share information when asked to clarify a medical quality issue.
• Two or more attempts made to contact physician/covering physician within a twenty-four (24) hour period to clarify/substantiate medical necessity for continued hospitalization; physician did not return phone calls.
• Adversarial interaction between the ConnectiCare representative and the physician.
• Inappropriate conduct by physician in attempting to discuss plan of care (e.g., hanging up phone prior to the end of the conversation, demeaning, rude or offensive behavior).
• Inadequate off-hours coverage
Examples:
• Office inappropriately instructs patient to go to emergency room/walk-in because office is closed.
• MD or a covering MD does not return call within an hour of being contacted.
• Abuse of billing practices
Health Delivery Organization (HDO) Compliance
ConnectiCare’s Quality Improvement Department has several monitoring activities in place for the ongoing assessment of our contracted HDOs.
Quality Improvement activities are essential to evaluate and promote physician and member satisfaction, as well as to evaluate the HDO’s compliance with ConnectiCare’s policies and standards. These activities are monitored on an ongoing basis in order to resolve problems and promote safe and efficient delivery of services.
Monitored activities may include but are not limited to:
• member satisfaction with provider services
• state survey inspection reports
• state regulatory action reports
• Medicare and Medicaid sanctions
• follow up regarding member and physician complaints about quality of care and quality of service
HDOs are required to comply with contractual obligations including compliance with ConnectiCare’s polices and procedures. Those organizations that are not in compliance are subject to potential sanction activity up to and including termination.
Quality of Care Issues
ConnectiCare’s Quality Improvement Department investigates quality of care issues received by any means. Those which are substantiated may result in suspension or termination. ConnectiCare may, at its discretion, suspend a provider immediately, prior to completing an investigation, when the quality of care issue indicates an imminent danger to the member. ConnectiCare’s medical director has the authority to suspend a provider.
In the case of suspension, the HDO may submit to ConnectiCare’s Quality Improvement Department evidence that the issue/or issues have been resolved and request a reconsideration of the suspension.
