• Quality of care — measured by clinical data related to the appropriateness of care and outcomes
• Efficiency of care — measured by clinical and financial data related to health care costs
• Member satisfaction — measured by the members’ reports regarding accessibility, quality of health care, member/provider relations and the comfort of the office setting
• Administrative requirements — measured by the provider’s methods and systems for keeping records and transmitting information
• Participation in clinical standards — measured by the provider’s involvement with panels used to monitor quality of care standards

Providers must:

• Comply with all applicable laws and licensing requirements.
• Furnish covered services in a manner consistent with professionally recognized standards of medical and surgical practice generally accepted in the professional community at the time of treatment
• Comply with IntegraNet standards, including:
• Guidelines established by the Centers for Disease Control and Prevention (or any successor entity).
• Federal, state and local laws regarding professional conduct.
• Comply with IntegraNet policies and procedures regarding the following:
• Participating on committees and clinical task forces to improve the quality and cost of care
• Prenotification and/or precertification requirements and time frames
• Provider credentialing requirements
• Referral policies
• Case Management Program referrals
• Appropriately releasing inpatient and outpatient utilization and outcomes information
• Providing accessibility of member medical record information to fulfill IntegraNet business and clinical needs
• Cooperating with efforts to assure appropriate levels of care
• Maintaining a collegial and professional relationship with IntegraNet personnel, health plan and fellow providers
• Providing equal access and treatment to all Medicare members

The following types of noncompliance issues are key areas of concern:

• Unnecessary out-of-network referrals and utilization (which require precertification)
• Failure to provide advance notice of admissions or precertification of discharges from inpatient facilities, comprehensive outpatient rehabilitation facilities or home health care services
• Member complaints and grievances filed against the provider
• Underutilization, overutilization or inappropriate referrals
• Inappropriate billing practices, such as balance billing of Medicare members for monies that are not their responsibility
• Non-supportive actions and/or attitude

Provider noncompliance is tracked on a calendar year basis. Corrective actions are taken as appropriate. Immediate terminations may be imposed due to the practitioner’s or HDO’s license suspension, probation or revocation, or if a practitioner or HDO has been sanctioned, debarred or excluded from the Medicare, Medicaid or FEHB programs, or has a criminal conviction, or an IntegraNet or health plan determination that the practitioner’s or HDO’s continued participation poses an imminent risk of harm to covered individuals. Participating practitioners and HDOs whose network participation have been terminated due to the practitioner’s suspension or loss of licensure or due to criminal conviction are not eligible for informal review/reconsideration or formal appeal. Participating practitioners and HDOs whose network participation have been terminated due to sanction, debarment or exclusion from the Medicare, Medicaid or FEHB are not eligible for informal review/reconsideration or formal appeal.