Quality Improvement Program

Program Overview

The Health Care Improvement Quality Program (“Program”) provides a formal process to measure and improve the Health Plan’s excellent quality ratings across all lines of business systematically and objectively.

The Program’s mission is to lead a dynamic and cross-functional quality program that demonstrates and drives excellence in quality and customer experience. The Program has a specific focus on “improving member and community health.” In addition to its quality focus, the program strives to achieve affordability and growth in all membership populations.

The key elements of the Program are aligned with regulatory requirements from the Centers for Medicare & Medicaid Services, including the CMS National Quality Strategy, the New York State Department of Health, and the National Committee for Quality Assurance.

The Program’s foundation is driven by an organization-wide improvement strategy, quality improvement program description, annual quality improvement evaluation of performance, and annual action plan. To support improvement efforts, monthly measurement and reporting functions are in place to trend and forecast performance.

Continued review of quality improvement activities requires ongoing:

• Execution of member engagement tactics to close gaps in care and improve experience
• Advancement of clinical data collection through partnerships with health information exchanges
• Continual monitoring of strategic action plans for all lines of business, including expansion of the Dual Special Needs Plan (D-SNP), and a focus on Medicare Stars
• Implementation of additional predictive analytics with integration of quality stratification for multiple-gap outreach and outcomes
• Evaluation of potential for additional Medicare value-based payment arrangements and/or new incentive programs to improve core quality metrics performance
• Aligned health equity regulations and strategies with Program initiatives and outcome reporting

For more information about the Program and our progress toward meeting our goals, review the Annual Health Care Improvement Quality Program Executive SummaryOpen a PDF.

How to Report a Concern With Quality of Care Received

If you would like to report a concern with the quality of care you or your family received from doctors, hospitals, or other healthcare facilities, please let us know. The Health Plan investigates and tracks these issues. Please contact Customer Service by calling the phone number listed on your Member Card, or follow this link to email Customer Service email Customer Service.

How to Report Medical Misconduct

Examples of medical misconduct include (but are not limited to): practicing fraudulently, practicing with gross incompetence or gross negligence; practicing while impaired by alcohol, drugs, physical disability or mental disability; being convicted of a crime; filing a false report; guaranteeing that treatment will result in a cure; refusing to provide services because of race, creed, color or ethnicity; performing services not authorized by the patient; harassing, abusing or intimidating a patient; ordering excessive tests; and abandoning or neglecting a patient in need of immediate care.

The mission of the New York State Department of Health Office of Professional Medical Conduct is to protect the public through the investigation of professional discipline issues involving physicians and physician assistants. OPMC is responsible for investigating all complaints of misconduct, coordinating disciplinary hearings that may result from an investigation, monitoring physicians whose licenses have been restored after a temporary license surrender and monitoring physicians and physician assistants placed on probation as a result of disciplinary action.

If you feel that your doctor has committed misconduct, you should file a report with the Office of Professional Medical Conduct. Reports of misconduct are kept confidential.