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  • Quality Improvement > Monitoring and Evaluation

    Quality Improvement Program Description

    The Quality Improvement Program Description is reviewed annually and amended as necessary. The review process incorporates input from the Quality Improvement Committee and final approval by the Quality Improvement Committee and the Quality Improvement Committee of the Boards and Quality Assurance Committee of the Board—the governing bodies. The timeline for completing the review process is set forth in the annual Quality Improvement Work Plan. Information about the Quality Improvement Program is published on EmblemHealth’s website

    The Annual Quality Improvement Program Work Plan (QIPWP)

    The Quality Improvement Work Plan encompasses quality and performance improvement activities that EmblemHealth will initiate, continue, complete, or terminate for all lines of business. The development of this review requires the cooperation of multiple departments, including, but not limited to: QualityManagement, Accreditation, Care Management, Utilization Management, Delegation, Behavioral Health, Customer Service, Claims, Enrollment, Marketing and Communications and Grievances and Appeals. This dynamic work plan reflects and integrates planned quality improvement activities throughout the year for all lines of business from all areas of the organization (clinical and administrative), and includes requirements for external reporting. The Quality Improvement Program Work Plan includes the following elements:

    • Yearly planned quality improvement activities and objectives for improving:
      • Quality of clinical and behavioral health care
      • Safety of clinical and behavioral health care
      • Quality of service
      • Members’ experience
    • Time frame for each quality improvement activity’s completion.
    • Staff member(s) responsible for implementation and management, initiation of the time frame, and the targeted completion date for each activity.
    • Planned monitoring and follow-up activities of previously identified issues.
    • Calendar of :
      • QI Committee Meeting Schedule
      • Presentation schedule for Quality Improvement Program documents
      • Presentation schedule for Utilization Management Program documents
      • Delegated activities reporting
      • Reports and documents to the Quality Improvement Committee and the Board of Directors.

    The status of the work plan items are updated quarterly and reviewed by the Quality Improvement Committee. The Quality Improvement Work Plan and its activities are subject to ongoing revisions and updates throughout the year as needed to meet changing priorities, regulatory requirements, and identified areas for improvement. Subsequent revisions and updates will be reviewed and approved by the Quality Improvement Committee.

    The Annual Quality Improvement Program Evaluation

    The Quality Management Assistant Vice President, Quality Improvement manager, and other applicable staff as identified, in collaboration with all relevant departments, prepare the annual Quality Improvement Program Evaluation, which:

    • Acknowledges the Quality Committee of the Boards’ oversight and evaluation of the Quality Improvement Committee, the effectiveness of the Quality Improvement Committee structure and organizational structures that support implementation.
    • Describes and evaluates completed and ongoing quality improvement activities that address quality and safety of clinical care, quality of service, and members’ experience.
    • Tracks the trending of measures such as HEDIS®, CAHPS®, and organization-specific key performance indicators, to assess performance in the quality and safety of clinical care and quality of service.
    • Analyzes and evaluates the impact, results, and effectiveness of quality improvement activities described within the program and work plan and of its progress toward influencing network-wide safe clinical practices. Focus includes, but is not limited to, delegated functions, SNP quality improvement projects, and the Chronic Care Improvement programs implemented during the year.
    • Identifies the limitations and barriers to improvement; analyses of barriers include staff who had direct experience with the processes and have presented barriers to improvement.
    • Identifies opportunities for improvement, including adequacy of resources, committee structure, practitioner participation, and leadership involvement in the Quality Improvement Program.
    • Recommends upcoming year’s activities, including those that will carry over into the next year.

    The Quality Improvement Program Evaluation is presented to the Quality Improvement Committee and the Quality Improvement Committee of the Boards for feedback and final approval, in accordance with the Quality Improvement Program Work Plan. Members, practitioners, providers, and employees are annually informed of EmblemHealth's Quality Improvement Program results through EmblemHealth’s website.

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    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.

    Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

    Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

    A pattern of medical care that focuses on long-term care with chronic diseases or conditions.

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.

    The process by which the organization permits another entity to perform functions and assume responsibilities covered under these standards on behalf of the organization, while the organization retains final authority to provide oversight to the delegate.

    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.

    A request to change an adverse determination that was based on administrative policies, procedures or guidelines.

    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.

    Specific circumstances or services listed in the contract for which benefits will be limited.

    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.

    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.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    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
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • 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.

    A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.


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