Quality Management

Quality Management

Maintaining standards of care

The Quality Management (QM) Program monitors and objectively evaluates the quality and effectiveness of care for our members.

Learn more about our Quality Management Program by visiting the sections below:

Quality Management Program

The Independence Quality Management (QM) Program is organized around a vision of supporting optimal health outcomes and satisfaction with care for our members, as well as meeting all applicable regulatory and accreditation requirements.

Program goals

  • Assess and improve the safety of medical and behavioral health care and services provided to members
  • Evaluate the sufficiency of the plan networks for members to access qualified providers for timely and appropriate care
  • Ensure evidence-based, effective care is provided to members for their medical and behavior health conditions
  • Promote efficient care and reduce health care waste through facilitating communication, continuity, and coordination of care among providers and supporting a focus on prevention and appropriate level of service
  • Promote health equity among diverse populations by identifying and addressing social needs, including access to care that fits cultural and linguistic preferences
  • Assess and address the satisfaction of members with their health care plan and services to support patient-centered system improvements

Program activities

The QM Program supports an ongoing comprehensive program of continuous quality improvement throughout the organization, monitoring the performance of our internal functional areas as well as the quality of care our members receive in our network. The program is based on comprehensive, integrated, and systematic processes driven by quality improvement principles and customer feedback. The QM team uses standardized measures of care and service quality to assess Plan performance and the performance of our network providers against our standards and goals. To identify and prioritize opportunities to improve clinical care and service, member safety, and member experience, the team supports the analysis of process and outcome measures. The QM Program convenes service and clinical quality committees monthly to assess performance, set goals, and develop performance improvement plans.

The QM Program implements the Member Safety Program, facilitates the organizational Population Health Management Strategy, and assesses the adequacy of the network. It also ensures delegation oversight, credentialing compliance, and clinical services compliance. Finally, it implements policies and procedures to ensure plan compliance with established standards of practice, NCQA accreditation standards and CMS, Pennsylvania, New Jersey, and other regulatory requirements.

Member Safety Program:

  • Reviews and addresses member adverse occurrences, complaints, and concerns about the health care they have received*;
  • Reviews claims data to identify potential safety and care quality issues, including medical and medication errors, for providers;
  • Educates network providers about effective safety practices and resources and Independence’s standards of care and access for our members;
  • Notifies network providers about gaps in members’ health care, errors, complaints, and adverse occurrences;
  • Coordinates with other internal departments to identify providers, patterns, and practices that could pose member safety and quality of care issues;
  • Ensures provider compliance with Plan quality standards through appropriate measurement, audit, and hearing processes;
  • Oversees processes for provider recognition in the provider directory for high-quality care, e.g., the Blue Distinction Center program;
  • Produces quality review reports to inform the Plan contracting process with providers;
  • Works with regional coalitions to bring providers together through collaborative patient safety initiatives and information sharing.

Population Health Management Strategy:

  • Monitors the health status and needs of our members, including identifying geographic and demographic differences in health factors;
  • Monitors and evaluates the care our members receive;
  • Monitors and facilitates care coordination capacity among providers and practitioners;
  • Synthesizes the various components of population health management into a cohesive organizational strategy and coordinates across the organization to drive progress toward the Triple Aim;
  • Evaluates the effectiveness of Plan programs and initiatives designed to improve the health outcomes, the value of care, and the experiences of our members, e.g. our preventive health outreach and condition management programs.

Network adequacy:

  • Evaluates the sufficiency of the plan networks for members to access qualified providers for timely and appropriate care;
  • Monitors the capacity of the network to offer access to high volume and high need specialties and linguistically and culturally appropriate care;
  • Verifies and monitors the credentials and good standing of all network providers.
  • Recognizes high performing providers and identifies providers with unsafe practices or non-compliance for education and corrective action plans;
  • Assesses and supports initiatives around change to level of care and scope of practice changes to coverage;
  • Assesses and addresses the satisfaction of members with their health plan and care.

Additional information about our Quality Management Program, including a description of our yearly plan and a report on progress, is available to members and providers, upon request. Provider requests, call 1-800-ASK-BLUE. Additional information about QM activities can also be found on our Provider News Center.

Members may request information about the QM Program by calling the Member Services number listed on the back of the ID card.

*Members who have concerns or complaints about the quality of care or service they received from a provider may call the Member Services number listed on back of the ID card and request to file a quality-of-care complaint.



NCQA accreditation

NCQA is an independent, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans, managed behavioral healthcare organizations, preferred provider organizations, new health plans, physician organizations, credentials verification organizations, disease management programs and other health-related programs.

NCQA Health Plan Accreditation evaluates how well a health plan manages all parts of its delivery system— physicians, hospitals, other providers and administrative services—in order to continuously improve the quality of care and services provided to its members. NCQA sends a team of trained health care experts, including physicians, to conduct a rigorous on-site survey of the health plan. NCQA uses information from health plan records, consumer surveys, interviews with plan staff and performance on selected HEDIS® measures.

Learn more about Independence’s accreditation statuses and other health care quality information on NCQA’s website at https://www.ncqa.org.



Access and availability standards

Independence Blue Cross (Independence) is committed to maintaining an adequate network of primary and specialty care providers to meet the needs and preferences of its members. To ensure access and availability to care, Independence has established standards for the number and distribution of providers in our networks as well as timeliness of care. Each year, Independence assesses how effectively our networks ensure appropriate access and availability of care to our members.

In order to meet the needs of our members, participating providers should adhere to the following standards:

Appointment availability

In the event of an emergency or immediate need, members should call 911 or go to the nearest emergency room. For non-life-threatening urgent care needs, an urgent care center, retail health clinic, or telemedicine visit may be an appropriate alternative for care if a primary care provider is unavailable. Members can use the Find a Doctor tool or visit MDLIVE’s website to learn more about these alternatives.

Provider type Access type Appointment availability within
Primary care provider Routine 2 weeks (4 weeks for routine physical)
Urgent 24 hours
Obstetrician/gynecologist Routine 2 months
Urgent 24 hours
Specialist Routine 2 weeks
Urgent 24 hours

Minimum number of office hours per practice per week

Practices are encouraged to have at least one weekend day or evening session per week.

Provider type Practice size Standard
PCP
Primary care provider Solo 20 hours
Primary care provider Dual 30 hours
Primary care provider Group 35 hours
Specialist
Chiropractor   20 hours
Capitated podiatry   20 hours
Specialist (other)   12 hours

Maximum number of patients scheduled per hour per physician

Waiting times in the office should not exceed 30 minutes from the time of the scheduled appointment.

Provider type Number of patients
PCP 6 patients
Specialist 4 patients
Podiatrist or chiropractor 6 patients
OB/GYN (routine) 6 patients

After-hours care

Providers should respond to after-hours urgent/emergency problems within 30 minutes. Coverage must be provided 24 hours per day, 7 days per week for our members. Providers who use answering machines for after-hour services are required to include:

  • Urgent/emergent instructions as the first point of instruction
  • Information on contacting a covering provider
  • A telephone number for after-hours physician access

 



Blue Distinction

Blue Distinction Centers® — recognized experience in specialty care

The Blue Distinction Specialty Care Program is a national Blue Cross and/or Blue Shield designation program recognizing healthcare providers that demonstrate expertise in delivering quality specialty care — safely, effectively and cost-efficiently. The goal of the program is to help consumers find both quality and value for their specialty care needs.

Blue Distinction Centers

The Blue Distinction Specialty Care Program includes two levels of designation:

  • Blue Distinction Center: Healthcare providers recognized for their expertise in delivering specialty care.
  • Blue Distinction Center+: Healthcare providers recognized for their expertise and cost-efficiency in delivering specialty care. Only those providers that first meet nationally established, objective quality measures for Blue Distinction Centers will be considered for designation as a Blue Distinction Center+.

What is specialty care?

Specialty care includes:

  • Bariatric (weight-loss) surgery
  • Cardiac care
  • Cellular immunotherapy*
  • Fertility care (physician designation)
  • Gene therapy*
  • Knee and hip replacement
  • Maternity care
  • Spine surgery
  • Transplants
  • Substance use treatment and recovery

*Only Blue Distinction designation available

Find a Blue Distinction Center

For a complete listing of the Blue Distinction Centers for specialty care nationwide, including those within the Independence Blue Cross provider network, please visit the BCBSA website.

Facilities that have attained the Blue Distinction Center designation will be marked in the online Find a Doctor tool.



Medical record keeping standards

Medical records facilitate the delivery of quality health care through the documentation of past and current health status, diagnoses, and treatment plans. As such, Independence Blue Cross (Independence) has established standards for medical records to promote efficient and effective treatment by facilitating communication and the coordination and continuity of care.

The Independence medical record standards policy is reviewed annually. The policy addresses confidentiality of medical records, medical records documentation standards, an organized medical record keeping system, standards for availability of medical records, maintenance and auditing of medical records, and performance goals to assess the quality of medical record keeping. Independence’s standards for medical record documentation are in addition to state and federal laws, including the requirements of the Health Insurance Portability and Accountability Act (HIPAA).

Each medical record should comply with the following standards:

Medical record content

  • Significant illnesses and medical conditions indicated on the problem list
  • Documentation of medications – current and updated
  • Prominent documentation of medication allergies and adverse reactions; if there are no known allergies or history of adverse reactions, this is appropriately noted
  • Food and other allergies, such as shellfish or latex, which may affect medical management
  • Past medical history (for patients seen three or more times), including serious accidents, operations, and illnesses; for children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses
  • For patients 12 years and older, appropriate notations concerning use of cigarettes, alcohol, and substance abuse (for patients seen three or more times, query substance abuse history)
  • History and physical documentation includes subjective and objective information for presenting complaints
  • Working diagnoses consistent with findings
  • Treatment or action plans consistent with diagnoses
  • Unresolved problems from previous office visits are addressed in subsequent visits
  • Documentation of clinical evaluation and findings for each visit
  • Appropriate notations regarding the utilization of consultants
  • No evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure
  • Documentation of preventive services and risk screening
  • Immunization record for children is up to date or an appropriate history is made for adults

Medical record organization

  • Each page in the record contains the patient’s name or ID number
  • Personal/biographical data include address, employer, home and work telephone numbers, and marital status
  • All entries contain the author’s identification; author identification may be a handwritten signature, a unique electronic identifier, or initials
  • All entries are dated
  • The record is legible to someone other than the writer

Information filed in medical records

  • All services provided directly by a primary care practitioner
  • All ancillary services and diagnostic tests ordered by a practitioner
  • All diagnostic and therapeutic services for which a member was referred by a practitioner (such as home health nursing reports, specialty physician reports, hospital discharge reports, and physical therapy reports)
  • Laboratory and other studies are ordered, as appropriate
  • Encounter forms or notes have a notation, when indicated, regarding follow-up care, calls, or visits; the specific time of return is noted in weeks, months, or as needed
  • If a consultation is requested, there is a note from the consultant in the record
  • Specialty physician, other consultation, laboratory, and imaging reports filed in the chart are initialed by the practitioner who ordered them to signify review; review and signature by professionals other than the ordering practitioner do not meet this requirement
  • Consultation: abnormal lab and imaging study results have an explicit notation in the record of follow-up plans
  • The existence of an Advance Directive is prominently documented in each adult (older than 18 years of age) member’s medical record; information as to whether the Advance Directive has been executed is also noted

Retrieving medical records

  • Medical records are to be made available to the Plan as defined in the Professional Provider Agreement

Confidentiality of medical records

  • Protected Health Information (PHI) is protected against unauthorized or inadvertent disclosure
  • At a minimum, medical records must be maintained for at least ten years, or age of majority plus six years, whichever is longer
  • Records are stored securely.
  • Only authorized personnel have access to records.
  • Staff receive periodic training in member information confidentiality

Maintenance of records and audits

Providers must maintain all medical and other records in accordance with the terms of their Professional Provider Agreement and the Provider Manual for Participating Professional Providers. When requested by Independence or its designated representatives, or designated representatives of local, state, or federal regulatory agencies, the provider shall produce copies of any such records and will permit access to the original medical records for comparison purposes within the requested time frames and, if requested, shall submit to examination under oath regarding the same. If a provider fails or refuses to produce copies and/or permit access to the original medical records within 30 days as requested, Independence reserves the right to require Selective Medical Review before claims are processed for payment to verify that claims submissions are eligible for coverage under the benefits plan.



Member rights and responsibilities

Commercial and Medicare Advantage member rights and responsibilities

Commercial member rights

  • The right to receive information about Independence, its benefits, services included or excluded from coverage, policies and procedures, participating practitioners/providers and member rights and responsibilities. Written and web-based information provided will be in a manner and format that is easily understood and readily accessible.
  • The right to be treated with courtesy, consideration, respect, and be recognized for his or her dignity and right to privacy.
  • The right to participate with practitioners in making decisions about his or her health care.
  • The right to voice complaints or appeals about Independence or the care it provides and receive a timely response about the disposition of the appeal/complaint and the right to further appeal, as appropriate.
  • The right to make recommendations regarding our member rights and responsibilities policies by contacting Customer Service.
  • The right to choose practitioners within the limits of covered benefits, availability, and participation within the Independence network.
  • The right to confidential treatment of personally identifiable health/medical information. Members also have the right to have access to their medical record, and ask that it be amended or corrected, in accordance with applicable federal and state laws.
  • The right to reasonable access to medical services.
  • The right to receive health care services without discrimination based on race, ethnicity, age, mental or physical disability, health status, genetic information, color, religion, gender, sexual orientation, national origin, source of payment, utilization of medical or mental health services or supplies, or other unlawful basis including, without limitation, the filing by such member of any complaint, grievance, appeal or legal action against Professional Provider, a Group Practice Provider (if applicable), or Independence.
  • The right to formulate and have advance directives implemented.
  • The right to obtain a current directory of participating providers in the Plan’s network, upon request. The directory includes addresses, telephone numbers, and a listing of providers who speak languages other than English.
  • The right to file a complaint or appeal about the health plan or care provided with the applicable regulatory agency and to receive an answer to those complaints within a reasonable period of time and to be notified of the disposition of an appeal or complaint and further appeal, as appropriate.
  • The right to appeal a decision to deny or limit coverage, first within the Plan and then through an independent organization for a filing fee, as applicable. A doctor cannot be penalized for filing a complaint or appeal on a member’s behalf.
  • For members with chronic disabilities, the right to obtain assistance and referrals to providers with experience in treatment of their disabilities.
  • The right to candid discussions of appropriate or medically necessary treatment options and alternatives for his or her conditions, regardless of cost or benefit coverage, in terms that the member understands, including an explanation of their complete medical condition, recommended treatment, risks of treatment, and expected results and reasonable medical alternatives. If the member is not capable of understanding this information, an explanation shall be provided to his or her next of kin or guardian and documented in the member’s medical record.
  • The right to available and accessible services when medically necessary, including availability of care 24 hours a day, 7 days a week for urgent and emergency conditions.
  • The right to call 911 in a potentially life-threatening situation without prior approval from Independence and have Independence pay per contract for a medical screening evaluation in the emergency room to determine whether an emergency medical condition exists.
  • The right to continue receiving services from a provider who has been terminated from the Independence network (without cause) in the timeframes as defined by the applicable state requirements of the member’s benefit plan. This continuation of care does not apply if the provider is terminated for reasons which would endanger the member, public health or safety, breach of contract, or fraud.
  • The rights afforded to members by law or regulation as a patient in a licensed health care facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the member understands.
  • The right to be free from balance billing by participating providers for medically necessary services that were authorized or covered, except as permitted for copayments, coinsurance, and deductibles by contract.
  • The right to be free from lifetime or yearly dollar limits on coverage of essential health benefits.
  • The right to be free from unreasonable rate increases and to receive an explanation of rate increases of 15% or more before your premium is raised.The right to prompt notification of terminations or changes in benefits, services or provider network.
  • The right to a choice of specialists among participating providers following an authorized referral, as applicable, subject to their availability to accept new patients.
  • The right to choose an individual On-Exchange health plan rather than the one offered by an employer and to be protected from employer retaliation.
  • The right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.

Commercial member responsibilities

  • The responsibility to communicate, to the extent possible, information Independence and participating providers need in order to provide care.
  • The responsibility to follow the plans and instructions for care that he or she has agreed on with his or her practitioners. This includes consideration of the possible consequences of failure to comply with recommended treatment.
  • The responsibility to understand his or her health problems and participate in developing mutually agreed upon treatment goals, to the degree possible.
  • The responsibility to review all benefits and membership materials carefully and to follow the rules pertaining to the health plan.
  • The responsibility to ask questions to assure understanding of the explanations and instructions given.
  • The responsibility to treat others with the same respect and courtesy expected for his or herself.
  • The responsibility to keep scheduled appointments or give adequate notice of delay or cancellation.
  • The responsibility to pay deductibles, coinsurance, or copayments, as appropriate, according to the member’s contract.
  • The responsibility to pay for charges incurred that are not covered under, or authorized under, the member’s benefit policy or contract.
  • For point of service contracts, the responsibility to pay for charges that exceed what the plan determines as customary and reasonable (usual and customary, or usual, customary and reasonable, as appropriate) for services that are covered under the out-of-network component of the member’s benefit contract.

Medicare Advantage member rights and responsibilities statement

Medicare Advantage member rights

  • The right to be treated with courtesy, fairness, respect, and recognition of his or her dignity and right to privacy.
  • The right to receive health care services without discrimination based on race, ethnicity, age, mental or physical disability, health status, genetic information, color, religion, gender, sexual orientation, national origin, or source of payment.
  • The right to confidential treatment of personally identifiable health/medical information. Members also have the right to have access to their medical record in accordance with applicable Federal laws.
  • The right to know treatment choices and participate with providers in making decisions about his or her health care in clear language the member can understand.
  • The right to get information in a way the member understands from Medicare, health care providers, and, under certain circumstances, contractors.
  • The right to get information in a way the member understands about Medicare and get answers to questions to help him or her make health care decisions, including what is covered, how doctors are paid, what Medicare pays, and how much they have to pay.
  • The right to choose participating doctors, specialists, and hospitals for medically necessary services within the limits of covered benefits, subject to their availability to accept new patients.
  • The right to a candid discussions of appropriate or medically necessary treatment options for his or her medical conditions, regardless of cost or benefit coverage.
  • The right to see Independence providers and get covered health care services and drugs within a reasonable period of time, in a language the member can understand and in a culturally sensitive way.
  • The right to get emergency care when you need it.
  • The right to use advance directives (such as a living will or a power of attorney).
  • The right to voice complaints (sometimes called grievances) or appeals about Independence or the care it provides and receive a timely response. Members have a right to be notified of the disposition of appeals/complaints and the right to further appeal, as appropriate.
  • The right to get information about Independence, its benefits, services included or excluded from coverage, its providers, and member rights and responsibilities. Written and web-based information provided will be readable and easy to understand.
  • The right to make recommendations regarding our member rights and responsibilities policy.
  • The right to get a decision about health care payment, coverage of services, or prescription drug coverage before getting services. If you disagree with the decision of your claim, you have the right to file an appeal.
  • The right to be free from lifetime or yearly dollar limits on coverage of essential health benefits.
  • The right to be free from unreasonable rate increases and to receive an explanation of rate increases of 15% or more before your premium is raised.

Medicare member responsibilities

  • The responsibility to give Independence and participating providers the information they need in order to provide care (to the extent possible).
  • The responsibility to follow the treatment plans and instructions for care that he or she has agreed upon with his or her practitioners. This includes consideration of the possible consequences of failure to comply with recommended treatment.
  • The responsibility to be considerate and act in a way that helps the smooth running of providers’ offices and facilities.
  • The responsibility to pay premiums and any cost-sharing owed for covered services and meet other financial responsibilities as described in the Evidence of Coverage.
  • The responsibility to understand his or her health problems and participate in developing mutually agreed upon treatment goals, to the degree possible.
  • The responsibility to advise Independence of any questions or concerns.
  • The responsibility to notify providers that he or she is enrolled in our health plan when seeking care (unless it is an emergency).
  • The responsibility to notify the health plan if he or she has additional health insurance or prescription drug coverage.
  • The responsibility to notify the health plan if he or she moves.


Privacy and confidentiality

Protection of privacy in all settings

Independence Blue Cross has taken numerous steps to see that the personal information of our members is kept confidential and to prevent the unauthorized release of, or access to, this information. All employees annually receive training regarding the importance of protecting member information. All contracted providers are required to maintain confidentiality of member information and records in accordance with applicable laws.

Access to medical records

Independence does not maintain members’ medical records. The providers who create the records are responsible for maintaining them. Members can access and obtain such medical records from providers. Independence does maintain records that contain personal health information as it relates to coverage. Upon a member’s request, we will provide a summary of any of his or her personally identifiable information maintained by us, such as telephone number, address, etc. At any time, a member may request that we modify, correct, change, or update his or her personally identifiable information that we maintain by contacting us by mail or telephone.

Inclusion in routine consent

In certain situations, it may be necessary for us to maintain and release a member’s records, claims related information, or health-related information to third parties for health care operations in accordance with applicable laws and regulations. Once enrolled with us, we may maintain and release member records to third-party vendors to ensure that quality health care coverage is provided to the member, to perform our contractual obligations, or to fulfill a regulatory mandate. Please be assured that we will only release information in accordance with applicable laws and regulations.

Right to approve release of information

Member information will only be released to qualified recipients and in accordance with applicable state and federal laws.

Use of measurement data

At times we may use membership data to develop or enhance health benefits and services. Patient identity will be kept anonymous wherever possible.



Utilization review

Affirmative statement regarding physician incentives for utilization management decisions

It is the policy of Independence and its affiliates (“plans”) that all utilization review decisions are based on the appropriateness of health care services and supplies in accordance with the plans’ definition of medical necessity and the benefits available under the member’s coverage. Only physicians can make denials of coverage of health care services and supplies based on lack of medical necessity.

The nurses, medical directors, other professional providers, and independent medical consultants who perform utilization review services for the plans are not compensated or given incentives based on their coverage review decisions. Medical directors and nurses are salaried employees of the plans, and contracted external physicians are compensated on a per-case-reviewed basis, regardless of the coverage determination. The plans do not specifically reward or provide financial incentives to individuals performing utilization review services for issuing denials of coverage. There are no financial incentives for such individuals that would encourage utilization review decisions that result in underutilization.


Contact us

If you have any questions or concerns about the quality of care received, you can reach us by calling the number on the back of your ID card.