BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

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BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire May 2012 SECTION 3 - QUALITY IMPROVEMENT Quality Improvement is an integrated process throughout the GHC organization. The Mission Statement for the GHC Quality Improvement program is: “To objectively and systematically identify opportunities for improvement and to continuously assess the effect of improvement activities in order to meet or exceed internal and external customer expectations.” This statement provides specific direction regarding the focus of quality improvement for GHC. In order to satisfy the goals of this mission statement, we feel that all GHC providers and facilities must collaborate with and embrace the activities of quality improvement. Such activities include satisfaction surveys, population and random sample based studies, and participation in multi-disciplinary teams for problem solving. These activities allow the organization to continuously improve upon processes of healthcare delivery in order to ensure that we are providing our members with highest quality of care in a cost-effective manner. Activities of quality improvement programs in HMOs are critically reviewed by organizations such as the Accreditation Association for Ambulatory Healthcare, Inc. (AAAHC) or National Committee for Quality Assurance (NCQA). We recognize that the consumer demands that organizations such as ours are held accountable for the services that are provided. Accreditation by organizations such as AAAHC or NCQA provides the consumer with assurances that the HMO has appropriate quality improvement structures in place and that those activities have a positive impact on healthcare delivery. In addition, the Wisconsin BadgerCare Plus/Medicaid SSI Managed Care Program requires that participating HMOs have effective quality improvement structures in place. As part of the State of Wisconsin BadgerCare Plus/Medicaid SSI program and HMO relationship, HMOs are required to provide the state with accurate encounter data within specified time frames. This data is collated and reported annually by the State of Wisconsin. Indicator data is reported in the following areas: Women's Healthcare; Child Healthcare; Acute and Chronic Condition; Mental Health; Preventive Care and Other Healthcare. Using this information, we are able to identify areas for improvement in serving these populations. The healthcare Provider's role in supplying this data is extremely important! With accurate information, we are able to provide better administrative support for our Plan Providers. Information from quality improvement activities is actively shared with our providers and staff. We encourage constructive feedback and are available as a resource for quality improvement activities of GHC providers and facilities. Questions or requests for information should be directed to the Quality Improvement Manager at the Administrative Offices at PO Box 3217, 2503 N. Hillcrest Parkway, Eau Claire WI 54702, 715-552-4300, or toll free 1-888-203-7770. [32]
BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire May 2012 SECTION 4– MEMBER RIGHTS & RESPONSIBILITIES MEMBERS HAVE THE RIGHT TO: Ask for an interpreter and have one provided to them during any covered service. Receive the information provided in their member handbook in another language or another format. Receive healthcare services as provided for in federal and state law. All covered services must be available and accessible to them. When medically appropriate, services must be available 24 hours a day, seven days a week. Receive information about treatment options including the right to request a second opinion. Make decisions about their healthcare. Be treated with dignity and respect. Be free from any form of restraint or seclusion used as a means of force, control, ease or reprisal. Member Civil Rights: GHC provides covered services to all eligible members regardless of: Age Race Religion Color Disability Sex Sexual orientation National origin Marital status Arrest or conviction record Military participation All medically necessary covered services are available to all members. All services are provided in the same manner to all members. All persons or organizations connected with GHC who refer or recommend members for services shall do so in the manner for all members. Translating or interpreting services are available for those members who need them. This service is free. [33]
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