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  • Podiatry > Quality Management

    To ensure appropriate patient care management, EmblemHealth performs periodic quality assurance reviews which may include practice pattern review, review of medical records, monitoring of referrals, review of specific clinical indicators, monitoring for over/under utilization and outliers, peer review, and other measures as determined by the EmblemHealth medical management committees and the Podiatry Professional Advisory Committee.

    EmblemHealth will also generate monthly reports profiling utilization by a podiatrist to ensure proper treatment of patients. We encourage practitioners to discuss their utilization information with our Medical Director, as well as with appropriate representatives from the Podiatry Professional Advisory Committee.

    For additional information regarding the Quality Management Program, please refer to the Quality Improvement chapter of this manual.

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    Glossary terms found on this page:

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.

    The process to objectively and systematically monitor and evaluate the quality, timeliness and appropriateness of covered services, including both clinical and administrative functions, to pursue opportunities to improve health care and resolve identified problems in any of these services.

    A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

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