Survey Our Annual HMO
Survey Parting the Clouds for a Clearer Look at the Current Landscape

Welcome to the 13th annual agents’ guide to managed care. Each year California Broker surveys health maintenance organizations (HMOs) in the state with direct questions about their plans. We then present the answers to such questions here for you—the professional agent or broker. We hope that this valuable information will help you serve your savvy healthcare clients better.

29. Describe the utilization process.

Aetna: Information is gathered from the physician and patient. The nurse consultant or physician reviewer and the attending physician discuss whether a test or treatment is appropriate. The physician reviewer can recommend alternative treatment and further testing. Protocol is reviewed annually. The consulting specialists, who are most familiar with procedure, review and approve any changes.
Anthem Blue Cross: The utilization management process is delegated to the PMGs/IPAs for our HMO product. They must have established review mechanisms, such as evidenced-based decision criteria and guidelines, which align with accepted medical practice. PMGs/IPAs maintain processes for referral management, pre-service, concurrent, and post-service review. Routine and active oversight is conducted to ensure compliance with regulatory and accrediting agency standards.
Blue Shield: We delegate our utilization management services to our contracted IPAs/medical groups. We conduct annual audits of their utilization management process to ensure compliance with our medical policy guidelines.
CIGNA: CIGNA physicians and nurses perform utilization management for inpatients in coordination with medical groups. To help ensure appropriate care and facilitate discharge planning, CIGNA reviews medical records for hospitalized members and consults with physicians via nurses located on-site at hospitals or by phone. Utilization review for most outpatient services is delegated to IPAs/Medical Groups. CIGNA HealthCare reviews inpatient procedures and hospitalizations, outpatient surgical procedures performed in a facility, transplants, and investigational therapies using Milliman Care Guidelines and CIGNA Coverage Positions. CIGNA utilization nurses (RNs) also conduct case management. Most outpatient referrals for specialists and procedures do not require prior authorization as long as the primary care physician requests them. However, CIGNA performs utilization review of select outpatient services when there is demonstrated value.
Health Net of CA: Health Net provides a multi-dimensional utilization/case management (UM/CM) program to direct and monitor health care services. It involves pre-service, concurrent, and post-service evaluation of the utilization of services provided to members. The UM/CM program is structured to ensure that qualified health professionals make medical decisions using written criteria based on sound clinical evidence without undue influence of Health Net management or concerns for the plan’s fiscal performance.
Kaiser Permanente: Our physicians plan our patient’s care and work with their peers to ensure appropriate treatment plans and use of resources. Utilization Management staff are available to support doctors in the management of member’s health care needs throughout the continuum of care and provide a variety of services such as discharge planning, utilization review, care management, and ensure compliance with internal and external regulatory requirements related to utilization management. The majority of utilization management, including reviews, is conducted internally as part of our integrated system of health care delivery. Kaiser Foundation Health Plan, Inc., Kaiser Foundation Hospitals, and the Permanente Medical Groups work in partnership to provide and coordinate medical management and review for our Health Plan members. Please note that department chiefs at the regional and facility levels handle utilization reviews. Members from Palm Springs, Ventura, and the Coachella Valley area receive utilization review via contracted physicians within our affiliated medical groups.
PacifiCare: We use industry-leading medical management programs to ensure that each enrollee receives the appropriate care necessary and that we control unnecessary health care costs for our clients. Our medical management programs focus on reducing variation, improving the quality of care provided and ensuring cost effectiveness. We base medical decisions on scientific evidence and all of our medical management services include physician guidance and input. We developed online, science-based and objective utilization management criteria as well as technology-based clinical decision support systems related to case, utilization and disease management.

30. Describe the Case Management Process.

Aetna: The following are some ways in which cases are identified: through the PCP or pharmacy, during certification reviews, during PMG/utilization management case reviews, and through other internal reporting and sources including member services, claims, and specialty programs. The case manager coordinates services for members who have multiple and complex needs. The case manager works with the PCP and the member to develop a care plan identifying services, frequency, duration, and goals. A team approach includes the PCP, specialist, member, family, caregiver, healthcare provider community, and internal programs to coordinate care, with a focus on member education and maximizing quality outcomes.
Anthem Blue Cross: The PMGs/IPAs perform in-area case management functions. Anthem case managers support PMGs/IPAs for members with exceptional needs or complex medical conditions. When appropriate, they manage out-of-area emergency admissions and help with transfers to in-area care. They also facilitate communication between healthcare providers and ensure that appropriate follow-up care is arranged with the PMG/IPA.
Blue Shield: Case management is a voluntary program that focuses on early identification and management of patients with potentially long-term and catastrophic healthcare needs. Candidates are identified using claims, authorization, and pharmacy data to identify potential candidates. The case manager helps identify appropriate cost-effective treatment options. Case management can follow members who are receiving alternative levels of care, such as inpatient rehabilitation, skilled nursing facility care, long-term home health services, and hospice services. Members who are using an acute facility three or more times in a six-month period can also be identified for case management. Utilization management, claims, and other medical operations team members can request case management for specific situations. Family members and providers can also request case management.
CIGNA: Members are identified via real-time and claims-based predictive modeling tools, along with referrals from physicians and medical groups, CIGNA clinical staff, and employers. Case managers collaborate with physicians, medical group case managers, members, and employers to facilitate ongoing treatment plans and support the primary care physician. Case managers monitor short-term and long-term goals for inpatient and outpatient care. They document and evaluate the effectiveness of the services provided. Besides traditional complex and catastrophic case management, CIGNA has a number of specialty case management units. They are staffed with RNs who are dedicated to areas, such as high-risk maternity, neonatal intensive care, oncology, obesity, and transplant. CIGNA has an extensive suite of disease management programs, including those for obesity complications and depression. CIGNA also offers online access to wellness information, care management services, and health coaching programs.
Health Net of CA: Health Net and its delegates provide case management/disease management programs to deliver individualized assistance to members in all lines of business who are experiencing complex, acute, or catastrophic illnesses or have exceptional needs. Health Net’s approach to utilization management extends far beyond traditional oversight. Health Net provides outreach to members with chronic conditions such as asthma, diabetes, COPD, heart failure, coronary heart disease, preference-sensitive conditions, and identification of members with cardiometabolic risk; uses population-based risk stratification and predictive modeling; and partners with physician groups to improve performance.
Kaiser Permanente: Case management is high-intensity, focused care for our sickest members, including those with high-risk pregnancies, cystic fibrosis, HIV/AIDS, end-stage renal disease, organ transplants, and complications from chronic conditions, as well as the frail elderly and the terminally ill. Members in need of case management are identified through clinical and utilization data from our disease registries, pharmacy records, hospital and outpatient visits, and laboratory results. Members can also self-refer to case management or be referred by a doctor or family. Our case managers, who are master’s-level clinicians or registered nurses, work directly with a member and his or her health care team to plan all of the member’s care and provide intensive coordination of services, including inpatient hospitalizations, transitional care, home care, skilled nursing, medications, referrals to community resources, and outpatient care. Using an interdisciplinary approach, case managers help to ensure continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining all authorizations or approvals as needed for outside services for members and their families. They’re also responsible for identifying quality-of-care problems and monitoring utilization issues.
PacifiCare: We designed our case management program to identify, intervene, coordinate and monitor care plans that provide high quality and cost-effective care for covered persons with catastrophic and complex health care needs. Our case managers facilitate communication and coordination of care between all parties on the health care team. This program involves the patient and family in the decision making process to minimize fragmentation in the delivery of health care. The case manager assesses the needs of the patient and educates them and the health care delivery team about case management, community resources, insurance benefits, cost factors and issues in all related topics so that informed decisions can be made. The case manager is the link between the patient, the providers, the payer and community.

31. Can the PCP participate in profits or losses in any way at the plan level or the participating medical group/IPA level?

Aetna: In California, Aetna participates in the IHA/7 health plan program of pay-for -performance. PCPs can participate in that IPA pay-for-performance bonus.
Anthem Blue Cross: Anthem established one of the first pay--for performance programs in California. We encourage our PMGs and IPAs to maintain a physician rating system with appropriate rewards for quality medical care. Physicians will get increased compensation for quality care. Our contract is not with the individual PCP. It is with the PMG/IPA with which we have risk sharing arrangements. Through a risk sharing arrangement we share cost savings for in-patient, emergency room, outpatient services and generic prescription rate with the PMG/IPA. The medical group/IPA may get incentives up to 50% of savings depending on the amount of costs saved.
Blue Shield: No, the PCP does not participate in profits or losses at the plan level.
CIGNA: The primary care physician does not participate in plan profits or losses in any way. The relationship between the PMG/IPA and the PCP is based on the contract between the two parties.
Health Net of CA: In 1993, Health Net of California introduced the Quality Care Improvement Program (QCIP). At the time, it based medical group compensation on member satisfaction scores. This program was enhanced in 1998 by incorporating quality-of-care outcomes into the compensation formula. In addition to contracted compensation, QCIP evaluates medical groups based on member satisfaction rates, quality–of-care outcomes, and collaboration. Additionally, Health Net evaluates medical groups’ cost performance measures. Similar to most health plans, shared-risk pools are incorporated with the compensation details for each Participating Physician Group (PPG). When the budget is established for the PPG’s medical services and hospital care, the PPG shares in the savings if costs do not consume the budget. Conversely, the group shares in paying for additional costs if the cost of care exceeds the budgeted amount. However, at no time does Health Net favor cost performance over quality. Recently, other California health plans have added programs similar to Health Net’s QCIP.
Kaiser Permanente: All of our physicians are eligible for an incentive payment based on the performance of our organization. Performance is measured by the collective results of each medical center. Each individual at the medical center can enhance the performance of the entire group. Incentive payments are based on several criteria including quality of care and member/patient satisfaction.
PacifiCare: We use a QIP (Quality Incentive Program) through which medical groups and IPAs can earn additional revenue by improving and maintaining patient safety, patient satisfaction, and quality of care. The QIP measures key indicators of quality in hospitals and medical groups based on the groups’ service and clinical quality. The QIP rewards medical groups and IPAs for attaining the required performance. The better a provider group performs in these categories the more QIP dollars they can earn. In 2003 the QIP was funded with $14 million and rewarded seventy-fifth percentile performers in 16 measures. Over 140 medical groups received rewards in 2003 and we achieved average mean score improvements in 12 of the 16 measures. In turn, average improvement for these measures increased 30 percent, a remarkable achievement. In 2004 our QIP expanded to include 20 measures, of which 17 improved an average of 20 percent. The incentive pool was $18 million in 2004 and is $65 million in 2005. In 2006, we paid out more than $96 million.

32. How are premiums and risk shared among the plan, MG/IPA

Aetna: The premium is not shared with providers. In California, we have some IPA risk share arrangements and an IPA or medical group share in savings if a target budget is not exceeded.
Anthem Blue Cross: Anthem has a capitated arrangement with the PMG/IPAs, which are responsible for payment of professional services. We promote clinical efficiency through a program of shared savings between the PMG/IPA and Anthem for expenditures related to capitated professional services. We have a program to share the savings for non-capitated inpatient care, outpatient care, and generic pharmacy prescription. Anthem is the largest sponsor of the IHA performance measures in the state and has the second largest pay for performance program in world behind only the United Kingdom’s.
Blue Shield: When there is no capitated hospital associated with the medical group, we establish shared risk arrangements for medical groups, but not with individual physicians. The shared risk arrangement does not affect payments to the group for professional services covered in the group’s capitation. The shared risk fund is set up to pay for services related to institutional fees. A fund is established for the group. Funding is made monthly and is tied to membership. Blue Shield pays for institutional services for group members from this fund. The group and Blue Shield share any money left in the fund at the end of the year. If there are negative figures, the negative balance is carried over to the following year.
CIGNA: Most medical group and IPA arrangements are capitated. Capitation does not contain provisions for withhold payments. For example, a lump sum is withheld and distributed later if the provider meets certain utilization targets. The standard contract is shared risk with CIGNA retaining risk for inpatient facility charges.
Health Net of CA: The majority of HMO physician services are paid under a pre-paid capitation payment to the contracted Participating Physician Group (PPG). The PPG, in turn, reimburses the physician directly for services.
Kaiser Permanente: Kaiser Foundation Health Plan (KFHP) contracts with the Permanente Medical Group (TPMG) in Northern California, and the Southern California Permanente Medical Group (SCPMG) to provide comprehensive medical services to KFHP members. The contractual arrangements are reimbursed at negotiated capitation rates as set forth in itemized budgets. The medical groups are reimbursed at negotiated capitation rates. A small portion is paid on an actual cost basis for specific items. Subject to limits on risk sharing, the medical groups are fully at risk for the capitated portion. They share the risk equally with the health plan for the actual cost portion.
PacifiCare: Currently all of our contracted medical groups and independent physician associations (IPA) participate in a risk-sharing arrangement. In addition, we contract with several networks of individual physicians in rural areas that do not participate in risk sharing. We contract with multi-specialty medical groups and independent physician associations (IPA) primarily through split or professional capitation contracts. Both contracts provide a monthly age, gender and benefit adjusted capitation. The risk-sharing arrangements are:

33. What happens when a member provider bills a participant for services? How do you deal with the fact that the participant is at financial or credit risk when the dispute is between the provider and the plan?

Aetna: Participating providers are required to accept payment (plus member’s co-payment) as payment in full. Balance billing is not permitted.
Anthem Blue Cross: Our first priority is to protect our membership from inappropriate billing. Our HMO providers are contractually required to refrain from billing members except for co-payments. If a participating provider bills a member, it is brought to the attention of the PMG/IPA liaison and the PMG is directed to pay the claim. If the PMG does not pay the authorized claim in 45 days from receipt, the plan pays the bill and debits the PMGs capitation payment for the ensuing period.
Blue Shield: Typically, our customer service representatives can resolve this type of case by contacting the provider’s office to clarify the correct patient liability. Providers are contractually prohibited from holding members responsible for any charges other than deductibles, co-payments, or non-covered services.
CIGNA: Yes, CIGNA offers a 24-hour health information line staffed with licensed nurses.
Health Net of CA: Health Net’s HMO contracts have a hold-harmless clause that prohibits medical groups from billing or collecting from members, except for standard co-payments and non-covered services. In the event a provider balance bills a member, Health Net removes the member from the situation and resolves the matter directly with the provider.
Kaiser Permanente: We are a prepaid, group practice HMO. Kaiser Foundation Health Plan (KFHP) contracts with The Permanente Medical Group (TPMG) in Northern California and the Southern California Permanente Medical Group (SCPMG) to provide comprehensive medical services exclusively to KFHP members. Providers do not bill members for services. Our providers are reimbursed at negotiated capitation rates; therefore, no disputes between the providers and the health plan would put members at financial or credit risk.
PacifiCare: Yes, at the plan level there is a 24-hour nurse line and medical audio library. Members can listen to pre-recorded health topics or speak with a licensed registered nurse. The nurse line staff can provide general counseling and triage recommendations. At the PMG/IPA level, PCPs are contractually required to provide after hours call coverage.

34. Do you have a nurse or RN on call 24 hours for questions at the plan level? At the PMG/IPA level?

Aetna: Yes, the Informed Health nurse-line is available to members. Network doctors are required to be available 24 hours a day.
Anthem Blue Cross: Anthem has a 24/7 Nurse Advice Line that is available for members. The member’s PCP or other covering practitioner is available to the member after hours and on the weekends if needed for non- emergent issues. The member may access the emergency room as needed for emergencies.
Blue Shield: Yes, as part of Blue Shield’s NurseHelp 24/7 program, members can get around-the clock online and telephone access to a registered nurse to get confidential advice and information about minor illnesses and injuries, chronic conditions, fitness, nutrition, and health related topics.
CIGNA: Yes, CIGNA offers a 24-hour health information line staffed with licensed nurses.
Health Net of CA: Health Net’s Decision Power program includes Health Coaches who are available 24 hours, 7 days a week. Members may call or email through Health Net’s website, www.healthnet.com, with questions or requests for information regarding chronic diseases, significant medical conditions, and medical questions. The Health Coaches are experienced clinicians who are ready to give individualized support through any medical situation.
Kaiser Permanente: Yes, our members can easily reach our specially trained advice nurses by telephone 24 hours a day, seven days a week. Using approved protocols, our advice nurses perform comprehensive triage to help members assess their symptoms and determine the level of care they need, such as self-care, an appointment with their PCP, a visit to urgent care, or a call to 911. When certain criteria are met, our advice nurses can also arrange for “telephone treatment” where members can get needed prescriptions for certain common conditions—including urinary tract infections, conjunctivitis, and sinusitis—without having to make an unnecessary visit to urgent care or their doctor’s office.
PacifiCare: Yes, treatments by Physician’s Assistant (PA) and Nurse Practitioner (NP) are included. However, the member has the right to request a physician examination.

35. Do you include treatment by a physician’s assistant (PA) or nurse practitioner (NP), rather than by a physician? Do you guarantee a physician exam for adults when requested by the patient?

Aetna: Yes, but physicians using Pass or NPs are required to oversee services. Members have a right to request a PCP.
Anthem Blue Cross: Treatment by a physician’s assistant or nurse practitioner is included in our coverage, if available at the PMG/IPA level. Members always have the right to see a physician, rather than a PA or NP, if desired.
Blue Shield: Yes, we include treatment by a physician’s assistant or nurse practitioner, but the physician partners are responsible for managing the treatment decision. We also guarantee a physician exam for adults.
CIGNA: Yes, when appropriate, physician’s assistants or nurse practitioners can work together with a physician. Yes, members can request an annual physical examination.
Health Net of CA: As long as a physician’s assistant or nurse practitioner is under the physician’s guidance and providing treatments under the scope of his or her license, treatment is covered. Members have the right to have exams conducted by physicians rather than physician assistants or nurse practitioners.
Kaiser Permanente: Yes, members can request a PCP, physician’s assistant (PA), or nurse practitioner (NP). PAs and NPs are licensed health care practitioners who work in a variety of specialties, including pediatrics, obstetrics/gynecology, cardiology, pulmonary medicine, and gastroenterology. PAs work under the supervision of physicians and NPs work collaboratively with and, when required, are supervised by doctors. NPs and PAs can diagnose and treat illnesses and in most states can order medications.
PacifiCare: Yes. We have terminated a small number of contracts with participating practitioners as well as delegated providers for failing to adhere to quality standards, typically less than one percent annually. The precipitating events included behavior presenting a potential risk of imminent harm to PacifiCare members and behavior contrary to the requirements of state and federal law. Our termination procedures adhere to contractual and regulatory requirements, and include informing the provider with required appeal rights and description of the appeal process.

36. Can doctors be terminated for over utilizing services?

Aetna: When inappropriate use of services, under/over utilization or quality issues are identified, the provider is counseled; an action plan for improvement is developed; and service activity is monitored. The provider could be terminated if performance does not improve.
Anthem Blue Cross: Anthem contracts with the PMGs/IPAs, which contract with the individual providers. If a physician does not correct inappropriate utilization after counseling, they may be subject to discipline, including possible termination, by either the PMG/IPA or Anthem Blue Cross.
Blue Shield: Yes, provider practices are reviewed for quality of care and utilization issues. Problems can be discovered from individual or patterns of claims submission, a subscriber complaint, or at the time of credentialing/re-credentialing. Often, further information is requested from a provider for a complete review of the problem. If the provider does not submit the requested information after several contacts, the provider is terminated for non-compliance with their contract, rather than the quality or utilization issue that prompted the review. Because the review cannot be completed, the termination is for administrative reasons, rather than for quality or utilization reasons.
CIGNA: CIGNA has never terminated a physician’s contract for over utilizing services unless there was evidence that it was hurting the quality of care or was fraudulent.
Health Net of CA: A Health Net peer review team measures and rates adverse action material submitted by the providers and various primary source agencies including the Medical Board of California, the National Practitioner Data Bank, the Healthcare Integrity and Protection Data Bank, Medicare/Medicaid Sanctions, Office of Inspector General, opt-out Medicare reporting, and the claims history for credentialing and re-credentialing. Health Net also investigates allegations made in the community and by the media. The provider has a right to appeal the decision through a fair hearing. Health Net uses quality data in physician management and evaluation to help identify potential provider issues.
Kaiser Permanente: Our integrated health care system ensures that not only our doctors, but also our entire network functions at optimal efficiency to manage utilization by implementing best practices. Outcomes from HEDIS and internal utilization reports are available online to doctors and administrators to help them assess appropriate care and access levels, capture long-term performance trends, and identify areas of potential over utilization and underutilization. The reports are also used to drive improvements in quality, access, and member services that result in improved outcomes, increased member satisfaction, and lower costs. Exceptions to best practice guidelines are identified, investigated, and corrected as needed.

37. How do you determine with which providers to contract? Do providers get incentives for refusing to contract with other plans (for example, to maintain a semi-exclusive relationship with a managed care plan)?

Aetna: It is monitored based on geographic access with the necessary mix of physician specialties and hospital services. An annual study determines the availability of PCPs relative to residence of member population. Providers don’t get incentives for refusing to contract with other plans.
Anthem Blue Cross: We consider geographic factors, experience of PCPs and specialists, board certification, and quality/reputation factors. We do not provide incentives for refusing to contract with other health plans.
Blue Shield: We have national criteria for selecting providers, which addresses credentialing, licensure, accreditation, affiliations, disciplinary actions, access, cost effectiveness, and quality of care. Blue Shield does not give providers incentives to limit contracting with other managed care plans.
CIGNA: Provider contracting is based on geographic, business, and member needs. Providers must meet credentialing criteria including verification of education and license status. There are no exclusive or semi-exclusive relationships.
Health Net of CA: To ensure the quality of the Health Net network, all potential Participating Physician Groups (PPGs) are subjected to intensive reviews to ensure they meet or exceed Health Net’s guidelines in the areas of medical management, financial viability and stability, and network accessibility. No incentives are given for refusing to contract with other plans.
Kaiser Permanente: We contract exclusively with the Permanente Medical Groups in Northern and Southern California to provide comprehensive medical services to members including primary care, specialty care, laboratory, and imaging services. Our doctors do not contract with other plans.
PacifiCare: Once we determine that network expansion is necessary, we research available providers in that area. We contact prospective providers for detailed assessments on their credentialing, quality assurance, and administrative capabilities. Before contracting, we assess area needs and hold initial discussions to gauge mutual interest. If this initial assessment is satisfactory, a provider delivery systems team begins contract negotiations. The length of the process varies depending on the urgency of need for additional providers and the availability of these providers during the auditing and contracting process. The process usually takes from two to six months. We do not offer anti-competitive incentives to any physician.

38. How can a member get information about a doctor’s schooling and malpractice suits?

Aetna: Plan service professionals have access to the plan’s national provider database, which generally includes the medical school of graduation. Malpractice information is not available.
Anthem Blue Cross: Members can get information about a doctor’s board certification status on the Anthem Blue Cross ProviderFinder directory web-based tool. Members can also request information about a doctor’s malpractice and schooling from the Medical Board of California via the Website, phone, in writing or they can contact the PMG/IPA directly.
Blue Shield: Members can access www.blueshieldca.com for information about a provider’s education. To get information about malpractice suits, members can contact the National Practitioner Databank in Washington, D.C. for a fee.
CIGNA: Members can call our Member Services department or look up the information on myCIGNA.com. Malpractice information is available to the public through the state medical board website. A peer review committee, which is staffed by CIGNA doctors and non-CIGNA doctors, reviews individual physicians’ histories before credentialing and re-credentialing the physician into the CIGNA network.
Health Net of CA: Members can contact Health Net’s customer call center to get information about a participating physician’s schooling. Members can also access Provider Search at www.healthnet.com for physician languages, board certification information, provider-specific information, and weekly and daily provider updates. Members can contact the Medical Board of California, the American Medical Association, or the applicable specialty board for information about a doctor’s malpractice suits.
Kaiser Permanente: Each medical center maintains physician information, which members can access to verify licensure, medical school graduation, residency, and fellowship training, and board certification. Members can contact the California Medical Association for malpractice information.
PacifiCare: The member can call customer service for educational history, licensing information and board certification. The member can call the Medical Board of California for malpractice information.

39. What are your grievance procedures?

Aetna: Our customer service professionals can respond to most issues by phone. If the issue cannot be resolved during the call, the customer service professional researches the inquiry and then responds to the member. Our goal is to respond to all inquiries in 15 business days. Members who are not satisfied with the response can file an oral or written grievance. We will forward a written notice stating the result of the review to the member in 30 business days of receiving the grievance. The decision is final and binding unless, in 30 days, the member submits a written request of the notice of the grievance decision for a hearing by the hearing panel/grievance committee. The member’s next course of action is to request an external review. The external reviewer decides in 30 days of the request. Expedited reviews are available when a member’s physician certifies that a delay in service would jeopardize the member’s health. Once the review is complete, we abide by the decision of the external reviewer. The Complaints and Appeals Tracking System was developed to support our national grievances and appeals process.
Anthem Blue Cross: Anthem is responsible for registering, investigating, and responding to member grievances and appeals. The appeal process is not delegated to the PMGs/IPAs. To file a grievance and appeal, the member should call the toll-free Anthem Blue Cross customer service number listed on their ID card or they can also submit a grievance in writing to the Anthem Blue Cross Grievance and Appeals P.O. Box. Members can also file an appeal or grievance online at www.anthem.com/ca. After we review the member’s grievance and appeal, the member receives a written statement of the resolution within 30 calendar days. The member has the right to request an expedited appeal if their condition is acute or urgent. Expedited appeals are resolved within three calendar days.
Blue Shield: Once a member has filed an appeal, Blue Shield assigns a grievance coordinator to call the member to get a clear understanding of their concern. The coordinator researches and forwards the grievance to all appropriate parties. Once a resolution has been made, the coordinator calls the member to inform them of the decision and the options that are available if they are dissatisfied with the resolution. Members who are dissatisfied with the resolution can request a second-level initial appeal review. During this review, members can appoint a representative or a provider to act on their behalf. If the member succeeds in their appeal and reimbursement is required, the coordinator will complete a payment request and submit it to the Grievance Resolution Department manager or supervisor for approval. All appeals are to be resolved in 30 calendar days.
CIGNA: Members can call Member Services or file a written complaint appeal. The complaint is investigated and reviewed in 30 days (when appropriate) and the member is notified of the decision. An expedited appeal can be filed when the member or provider is concerned with potential loss of life or health or the ability to gain maximum function. When necessary, procedures are modified to meet or exceed applicable regulatory and accreditation guidelines.
Health Net of CA: Health Net of CA: When members complain about the quality of service provided by the plan or its participating practitioner, the grievance is documented and researched and an acknowledgement letter to the member within five days. The hospital/ PPG/practitioner has seven days to respond to the grievance. The final resolution letter will be sent to the hospital/PPG/practitioner. If it takes longer than 30 days to resolve, a letter of explanation will be sent to the member. The grievance is documented when members complain about the direct provision of care or the quality of care by a participating provider. If the matter is urgent, it will be forwarded to a clinical specialist for immediate attention and resolution (If required, care will be provided to the member). An acknowledgement letter and medical records release form will be sent to the member within five days. The hospital/PPG/practitioner has seven days to respond to the grievance. Health Net will determine if the grievance can be resolved with the records at hand if the member does not provide out-of-plan records or if the medical record release form is not signed. If it can’t, the case is closed until all necessary information is provided. After review, a letter to the member will communicate the disposition. The final resolution letter will be sent to the hospital/PPG/practitioner. If the matter takes longer than 30 days to resolve, a letter will be sent to the member to explain the delay and provide an estimated resolution date.
Kaiser Permanente: Our members can submit complaints to the member service representative at the facility through the call center. The complaint is acknowledged within seven calendar days. A response is made within 30 days after it has been submitted. A complaint or grievance will be resolved within 60 days from the date it was received by plan. An external, independent, third party review process is available to non-Medicare members who have completed the internal grievance/appeals process.
PacifiCare: Our top priority is for members to receive the services they need. If a problem occurs we encourage members to contact our Customer Service department as their first source for resolution. This team will make every effort to find a solution to the member’s situation. If the situation requires additional action, the member may submit a formal complaint requesting an appeal or quality review. The process includes the following:
• A Quality of Clinical Care and Quality of Service Review.
• Appeals Process for Quality Review.
• Voluntary Mediation and Binding Arbitration.
• Independent Medical Review.

40. What systems are in place for assessing participant satisfaction?

Aetna: Member satisfaction is measured yearly at the network level using CAHPS 2.0H survey. The plan administers the most recent survey required by HEDIS to assess satisfaction. We also participate in the Consumer Assessment Survey to evaluate member satisfaction with IPA and Medical Groups.
Anthem Blue Cross: Anthem conducts a variety of surveys each year to measure our members’ health and satisfaction and improve the quality of care and customer service. We conduct a semi-annual customer satisfaction service survey, an annual consumer assessment of health plans, and an annual consumer assessment survey to assess the quality of care at the PMG/IPA level.
Blue Shield: Our Quality Management and Improvement Program is designed to comply with recognized industry requirements and standards established by the National Committee on Quality Assurance, Knox-Keene regulation, Department of Managed Healthcare, and the Center for Medicare & Medicaid Services. Our Quality Management Committee and the Board Quality Improvement Committee review and amend the program annually. We use HEDIS measures to monitor member satisfaction surveys, member inquiry analysis, disenrollment, member appeals, access to care and quality of service, and medical record audits and office site reviews.
CIGNA: CIGNA uses the HEDIS CAHPS member satisfaction survey. The health plan participates in the Consumer Assessment Survey, which analyzes member satisfaction with medical groups and addresses utilization management, appointment wait times, office staff, etc. We continually monitor and improve member satisfaction.
Health Net of CA: Three online customer satisfaction surveys are being conducted among primary constituents: members, employer groups and brokers.
Kaiser Permanente: We conduct ongoing surveys to evaluate member and patient satisfaction with doctors, access to services, and quality of care. Survey feedback is disseminated throughout the organization to target areas for improvement.
PacifiCare: PacifiCare uses the NCQA CAHPS annually to assess patient satisfaction with their care. Our satisfaction results are reported in our annual HEDIS results. CAHPS is a mail survey, which fulfills a component of the NCQA accreditation process. A telephone follow-up and interview occurs among non-responders per NCQA specifications.

41. Do you participate in outcomes research? Do you provide physician performance review data to the public?

Aetna: Yes, HEDIS is available for public review through the California Cooperative HEDIS Reporting Initiative.
Anthem Blue Cross: Yes, we have tools that support predictive modeling, provider profiling, hospital profiling, disease management, network analysis, quality assessment, regulatory reporting, and HEDIS submission. Additionally, Anthem has acquired HealthCore Inc., a leading outcomes research company. Performance review data for our PMGs/IPAs is available publicly on our website and in provider directories.
Blue Shield: Yes, Blue Shield of California conducts outcomes research for disease management programs and participates in broader research efforts. Collaborative studies may be published. For example, the results of a controlled study of complex case management outcomes are being prepared for publication. Blue Shield is a sponsor/participant in IHAs Pay for Performance project. The California Cooperative Healthcare Reporting Initiative and California’s Office of the patient advocate provides public reports of medical group performance and information technology measures. Efficiency measures are being developed and tested to be added to the report.
CIGNA: CIGNA is accredited by the NCQA and participates in reporting HEDIS clinical outcome data, which is available for public review. CIGNA HealthCare participates in the Integrated HealthCare Association’s Pay for Performance program. It provides data at the medical group level, which is reported to the public annually through the state’s Office of Patient Advocate. CIGNA also participates in the California HealthCare Foundation’s CHART hospital quality initiative. Through myCIGNA.com, the company offers an array of information about provider and hospital quality for its members.
Health Net of CA: Medical groups are rated on wide-ranging quality--of-service and quality-of-care measurements. Results are available at www.healthnet.com, where members can view the Hospital Comparison Report and Participating Physician Group Report on a number of quality-of-care and service measures.
Kaiser Permanente: The most recent developments in medical out-comes research are incorporated into our evidence-based Clinical Practice Guideline program, assessed by our New Technologies Committee, and incorporated into our extensive library system with online capabilities. In addition, our clinicians are involved in a broad scope of clinical, epidemiological, and health services research projects. We earned ratings of “Excellent” in the latest review by the National Committee for Quality Assurance. We also routinely get high scores in many outcomes based surveys, such as HEDIS, Leapfrog, and METEOR, which measure our member satisfaction. Physician performance reviews are not available to the public.
PacifiCare: Yes. Outcome results are incorporated into our provider group profile, which compares each provider group with network averages. We release these performance results to the public through our quality index profiles. The reports look at clinical, service and administrative quality measures. PacifiCare motivates provider compliance by intervening aggressively when deficiencies are found and by sharing best practices when excellence is identified.

42. Do you notify members when their PCP is no longer a member of the plan? How?

Aetna: Yes, members are notified by letter. They are apprised of transition of care issues and instructed on how to select a new PCP.
Anthem Blue Cross: Yes, PMGs/IPAs are required to provide 90 days notice to the plan when a physician within the PMG/IPA leaves the group or is terminated from our network. The PMG/IPA must offer the services of another PCP within the group. The plan provides at least 60 days’ notice in writing to all members enrolled with the terminating PCP. This letter includes the name of their new PCP or medical group.
Blue Shield: Yes, we are regulated by the Department of Managed Healthcare, which requires written member communication of network changes 60 days before the effective date of the change. For IPA or medical group terminations, we use a standardized communication and transition process. First, we analyze network access using GeoAccess software to determine how provider termination affects the member. Second, we determine which primary care physicians in the terminating IPA or medical groups are affiliated with other Blue Shield contracted IPAs and medical groups. We then transition affected members, as necessary. If their personal physician is affiliated with another contracted IPA/medical group, the member goes to the new group and maintains their physician. If their personal physician is not affiliated with another contracted IPA/medical group, the member goes to a new personal physician in a new medical group. Letters relating this to the members are mailed at least 60 days before the effective date of the transition. Employers also get written notification along with copies of the member letters.
CIGNA: If a PCP is no longer a member of our health plan, members are notified by mail about 60 days before the effective date and are encouraged to choose a new PCP.
Health Net of CA: Health Net Participating Physician Groups and individually contracted physicians are required, by contract, to notify us of any changes to the provider network including new physicians joining the PPG, address and telephone number changes, and physician terminations. Health Net notifies our members when their PCP leaves the network or becomes affiliated with a different contracting PPG. Members can follow their PCP to a new contracting PPG. Members can choose a new PCP within the network or remain with their PPG if their PCP is no longer available in our network. When possible, members will receive a written notice within 30 to 60 days of the provider’s decision to leave the network. Provider listings are available at www.healthnet.com and are updated daily.
Kaiser Permanente: Yes, each medical center has developed general protocols to facilitate the transition of care to another doctor. All patients who are scheduled to see the physician for outpatient care are contacted to reschedule with another plan doctor.
PacifiCare: Yes. PacifiCare sends a notification letter to all affected members 30 days prior to the termination date of a physician or medical group. The member selects a new PCP or medical group. If the member does not select a PCP or medical group within 30 days, we automatically assign a PCP or medical group that is geographically closest to their residence. If the member is unhappy with the assigned provider, he or she may request a change at any time by calling customer service.

43. What action is the plan or the IPA/MG taking to have online eligibility, administrative changes, referrals, etc?

Aetna: We participate in the Work Group for Electronic Data Inter-change, the Computerized Patient Record Institute, and the American National Standards Institute. A monthly eligibility file is provided to IPAs and Medical Groups.
Anthem Blue Cross: Through our Internet application, EmployerAccess.com, group administrators can process eligibility transactions including additions, changes, and cancellations. (Changes are processed in real-time, assuming a confirmation response is received.) The administrator can also order ID cards; perform quick inquiries on employees; and locate providers via our provider finder. The “EmployerAccess.com” application features confidential and secure data through user ID and personal identification numbers, drop-down menus for easy point-and-click operation, and easy to follow hyper-link steps to guide the administrator through electronic enrollment, benefit changes, and maintenance processes.
Blue Shield: We are fully HIPAA compliant, ensuring secure electronic and online transactions. We offer electronic enrollment and eligibility maintenance capabilities for our employer groups. We support all file types, including ANSI 834, File Express, text files, Excel, and other spreadsheet and proprietary formats. We also offer Web-based enrollment and eligibility via file transfer protocol. We can also work with any third-party benefit administration vendor for Web-based enrollment and eligibility that our employer groups can be using. We also give employers access to standard reports and utilization data online via a secure client portal site. Our award-winning Website at blueshieldca.com enables members to set up and manage their accounts online. Members can submit address changes online; download claim forms, e-mail customer service, and request duplicate ID cards. They can also access online claim status, EOB information, provider directories, and a wealth of educational information about staying healthy and active. Other features include an online Q&A service, a hospital comparison tool, a treatment options tool, and a drug interactions tool.
CIGNA: CIGNA recently enhanced the provider website offering easy access to online eligibility, detailed benefit information, claims tracking, and a new claim coding disclosure tool, which offers an immediate response to inquiries. For members, myCIGNA.com offers online eligibility tools, claims support, and other tools that allow members to select or change their PCP and get personalized medical information and provider quality data. In addition, CIGNAaccess.com provides a single point of access to online tools and services to help make benefits administration easier. CIGNAaccess.com is a resource for employers in employee support, benefits administration, and security administration.
Health Net of CA: At www.healthnet.com, brokers, employers, providers, and members can perform wide-ranging administrative functions, including eligibility verification. The Broker Solutions site provides online applications, product and rate information, provider directories, email access, and more. Members can access secure information about their coverage, and correspond with Member Services, order ID cards and forms, file grievances, change addresses, check eligibility/benefits, change PCPs/ PPGs, view a pharmacy drug list, search for providers, look up information for their specific needs, get pharmacy refills, and more. In addition, Health Net uses the Internet to help employer groups make processing eligibility changes and pay bills. It is a free service to employer groups. Employer groups can log onto www.healthnet.com or eServices.healthnet.com.
Kaiser Permanente: Eligibility files are processed by our extensive mainframe system, which is linked to our California Service Center in San Diego. Account representatives update membership online and nightly (via electronic media files from purchasers). When the membership is updated, eligibility is updated automatically. Nightly interfaces supply membership eligibility information to other clinical systems. These files feed all claims and membership systems. A computer tape back up is maintained.
PacifiCare: PacifiCare providers can check eligibility and claim stat us; print common forms; and view the specialty referral list at www.pacificare.com. We offer a paper and electronic referral process. In California, providers can access iExchange via the Web for electronic preauthorization requests and hospital admission notifications. The process varies for networks that are delegated and managed by contracted providers. Some providers have electronic referral systems in their own specialist network and others use paper submission. We do not track electronic referrals for these providers since they track these statistics internally.

44. How has your plan changed from last year?

Kaiser Permanente: The following changes occurred as contracts renewed in 2009:
• We made available for sale optional differential primary care and specialty care co-payments that apply a higher co-payment for visits with specialty care providers than for visits with primary care providers.
• For our Traditional HMO customers who have been asking for inpatient and outpatient coinsurance without a deductible, we introduced partial plan coinsurance (for inpatient services only) and full plan coinsurance (for inpatient and outpatient services). Plan coinsurance requires a deductible platform to correctly adjudicate and accumulate coinsurance.
• Infertility services ceased to accumulate to the Maximum Out of Pocket (MOOP) on Traditional HMO plans. Infertility is also no longer subject to the Deductible and ceased to accumulate to the MOOP on Deductible HMO plans. Members with coverage for infertility services pay their applicable cost share (coinsurance or co-payment) for infertility services for as long as they receive these services.
• The cost share for single-source generic drugs is now the generic drug cost share (co-payment or coinsurance).
• Presbyopia-correcting intraocular lenses (IOLs) are excluded from coverage on all non-Medicare plans. This includes presbyopia-correcting IOLs related to cataract surgery.
• The cost share for an inpatient stay is now the cost share in effect on date of admission, through discharge.
• Artificial insemination and sperm collection, processing and testing is now covered at no charge as a preventive service not subject to the deductible for HIV negative women who wish to conceive using sperm from HIV-positive donors.
PacifiCare: There are no significant changes to the general plan structure from last year; however, there is flexibility on how plans are quoted. Clients requesting customization work closely with their broker to determine the best possible options for their company.