In line with EmblemHealth’s Corporate Mission, as a quality-driven organization, EmblemHealth has adopted Continuous Quality Improvement in medical (including pharmaceutical and dental) and behavioral health care and service provided to a complex, culturally and language diverse membership as a core business strategy. Our Executive and Management teams use data-driven, decision-making methodologies in the strategic planning process. EmblemHealth has adopted the Institute for Healthcare Improvement (IHI) and the Centers for Medicare & Medicaid Services (CMS) Triple-Aim for Healthcare Improvement. We strive to simultaneously improve the health status of our members, improve each member’s experience of care, and reduce the per capita cost of health care. As a result of this ongoing improvement and monitoring process, EmblemHealth will better serve the needs of members, including all demographic groups and those with special needs, as well as employers, employees, participating practitioners, providers, accounts, service partners, brokers, consultants, and regulatory and accreditation bodies. Toward this end, the goals and objectives of the Quality Improvement Program are to:
- Improve the health status of our members.
- Improve the member/provider experience of health care and services.
- Reduce the per capita cost of health care.
- Address members’ complex needs (medical and behavioral health) through quality of care, coordination of care, disease management, and case management initiatives.
- Address specific monitoring requirements related to special populations, such as Medically Fragile Children, to ensure benefits and services are appropriately delivered.
All goals and objectives are in alignment with applicable regulatory and accreditation requirements.
Glossary terms found on this page:
An evaluative process in which a health care organization undergoes an examination of its policies and procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.
Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.
Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).
A program that assists the patient in determining the most appropriate and cost-effective treatment plan, including coordinating and monitoring the care with the ultimate goal of achieving the optimum health care outcome.
The government agency responsible for administering the Medicare and Medicaid programs.
A coordinated system of preventive, diagnostic and therapeutic measures intended to provide cost-effective, quality health care for a patient population who have or are at risk for a specific chronic illness or medical condition.
An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.
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 jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes
A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.
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.