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Quality Management

Quality Improvement Programs
Health Care Partners of Nevada (HCPNV) has Quality Improvement Programs that are responsible for the development and reporting of quality initiatives. These are improvement guidelines for the care of HCPNV Commercial and Medicare members who live in Southern Nevada. The Quality Improvement Programs are used throughout HCPNV and each department is responsible for meeting set performance standards, reviewing processes and procedures, providing excellent service to members and providers, and finding new ways to add value to our products.

The HCPNV Medical Management Program is designed to monitor, evaluate and positively influence the provision of cost-effective medical care or services throughout the organization or its affiliates. This purpose is accomplished through Medical Services, Inpatient Services, Corporate Risk, Clinical Compliance, Quality Management, and contracted Behavioral Health Providers.

Utilization review services for self-funded and Health Maintenance Organization (HMO) populations are provided through electronic, telephonic or face-to-face interactions with members and providers.

HCPNV Medical Management Plan
The HCPNV Medical Services Organization (MSO) composes an annual Medical Management Plan. The Medical Management Plan specifies the programs goals, objectives, scope and organization structure as well as performance standards.
  • 2011 HCPNV Quality and Medical Management Program Description
The HCPNV Behavioral Health Program includes the assessment, monitoring, and improvement of all aspects of behavioral health care and the services received by our members. These include:
  • Outpatient Services - Individual counseling, substance abuse counseling, family counseling, and urgent care clinic
  • Community Services - Rapid Response Intermediate Care, intensive outpatient programs, structured adult dependency programs, and partial hospitalization programs
  • Care delivered in the hospital for psychiatric care, or acute hospitalization for substance abuse
  • All types of behavioral health care services delivered by all types of practitioners and providers
  • Services delivered by HCPNV, Harmony Healthcare, and its employees and contracted providers
HCPNV works with Harmony Healthcare, L.L.C., to provide quality care to our members in both Clark County and Nye County, Nevada.

HPCNV Behavioral Health Program Description and Work Plan

The HCPNV Medical Services Organization (MSO) implements an annual Behavioral Health Program Description and Quality Improvement/Utilization Management Work Plan. The Program Description provides a detailed outline of our program and the work plan details the specific activities, objectives and performance standards.

Affirmative Statement Regarding Incentives

What is an affirmative statement?
It is a document signed by all employees, practitioners, and providers required to make utilization-related decisions and those who supervise them.

What does it specify?
It states that the person or persons signing understands the following:
  • UM decision-making is based on appropriateness of care and services and existence of coverage
  • The organization does not specifically reward practitioners or other individuals for issuing denials of coverage or service care
  • Financial incentives for UM decision makers do not encourage decisions that result in underutilization
  • Incentives, including compensation, for any person are not based on the quantity or type of denial decisions made
HealthCare Partners Nevada does not use incentive to reward inappropriate restrictions of care but may allow the use of "appropriate incentives for fostering efficient, appropriate care".

Utilization Management (UM) Criteria

What criteria are used for UM decisions?
The UM program functions on consistently applied systematic evaluation of appropriateness criteria. The criterion is selected based on nationally recognized standards of practice for medical services and is applied on an individual needs basis. Criteria used for utilization review decisions are from CMS, Milliman Care Guildelines, Diagnostic & Statistical Manual of Mental Disorders (DSM-IV), American Society of Addiction Medical (ASAM) criteria as well as approved HealthCare Partners Nevada (HCPNV) guidelines. Nurse Reviewers and Medical Directors are knowledgeable and experienced with the criteria. Their consistent application of the criteria is assessed on a semi-annual basis. Each practitioners' office has written instructions in the application of Milliman, DSM-IV, and ASAM criteria. The Quality Medical Management Committee (QMMC) reviews the Milliman, DSM-IV, and ASAM criteria as well as the HCPNV guidelines/policies annually for changes and updates.

What if a criterion doesn't apply or is not appropriate?

When UM criteria or guidelines are not appropriate for the case in review, the reviewer will submit all information to a Medical Director for individual consideration and discussions with providers in the same or similar specialty for standards of care and practice. The following factors are included in individual consideration decisions:
  • Age of the member
  • Co-morbidities
  • Complications
  • Progress of treatment
  • Psychosocial situation
  • Home environment, if applicable
  • Network composition, i.e. availability of skilled nursing facilities, home care
  • Benefit coverage
  • Capabilities and services of the network or out of network facilities
  • Community resources for discharge planning and follow up care
How often are the criteria reviewed?
The consistent application of the criteria is evaluated at least once a year for all nurse and physician reviewers. Opportunities for improvement are identified with individual feedback given to the reviewer. Each nurse and physician reviewer must reach a comprehensive score of ninety (90) percent on the inter-rater reliability assessment in order to continue making medical necessity decisions. Criteria used in decision-making are available to practitioners, facility personnel, providers and members upon request to HCPNV.

Where can I get more information?
The program description, annual work plan and evaluation, and Utilization Management decision making criteria is available at your request. If you are interested in receiving a copy please contact HCPNV's Quality Management department at 702.318.2450.

Peer to Peer Discussions for Medical Necessity Denials
The Health Care Partners of Nevada (HCPNV) Utilization Management Department ensures that a physician reviewer is available to discuss medical necessity denials and how to contact the reviewer. This is called a "Peer to Peer" discussion.

An appropriate practitioner by specialty, will be assigned by HCPNV to talk to the practitioner about a UM denial decision. The reviewer may be a physician, pharmacist, chiropractor, dentist or other practitioner type as appropriate.

This opportunity will be afforded to you and documented by HCPNV, either before or after the issuance of the denial. Peer to Peer discussions are not only for denials, but in many cases, for identifying the opinion of the provider, Medicine is not black and white, and in some cases the reviewer can override the criteria based on Peer to Peer review.

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