Scope of the ValueOptions’ Quality Management Program
The VO-KS Quality Management Program monitors and evaluates quality across the entire range of services.The program is intended to ensure that the structure and processes in place lead to desired outcomes for both members and providers.
The scope of the QM Program includes:
- Clinical Services/Utilization Management Programs;
- Quality Improvement Activities/Projects;
- Outcome Management;
- Network Management/Provider Relations Activities;
- Satisfaction Surveys;
- Clinical Treatment Record Evaluation;
- Service Availability and Access to Care;
- Practitioner and Provider Quality Performance;
- Member and Provider Grievances;
- Member Rights and Responsibilities;
- Member Safety Issues;
- Clinical and Administrative Denials and Appeals;
- Quality Indicator development and monitoring; and
- Cultural Competency.
Confidentiality
ValueOptions’ employees routinely maintain as confidential all information collected relating to past and present members, including identity, as well as personal information.
- Protected Health Information (PHI) is maintained on a confidential basis in accordance with all applicable regulatory requirements. ValueOptions ensures that all such information obtained during the utilization management process is used solely for the purposes of utilization management, quality management, disease management, discharge planning, case management, and claims payment. All ValueOptions’ employees are required to sign a statement of confidentiality at the time of employment and every annual evaluation thereafter. All ValueOptions’ employees, providers and delegated entities are expected to safeguard the confidentiality of Utilization Management (UM) and Treatment Records information related to both enrolled and disenrolled members. ValueOptions maintains information systems to collect, maintain, and analyze information necessary for utilization management that incorporates adequate safeguards to ensure the confidentiality and security of UM and Treatment Records as well as a plan for secure storage, maintenance, tracking and destruction of member-identifiable clinical information.
- All requests for authorizations for disclosure of information are reviewed and responded to in accordance with ValueOptions’ policy, as well as all applicable laws and regulations.
Members are entitled to receive copies of any information pertaining to themselves, on request, subject to limits placed by state and federal guidelines, and an evaluation of any potential risk of harm to the member entailed by such disclosure of information.
- Confidential information may include but not be limited to:
- Protected Health Information (PHI);
- Certification of mental health treatment;
- Claims processing information;
- Utilization review;
- Peer review;
- Appeals; and
- Quality assurance
Individuals engaged in quality improvement activities maintain the confidentiality of the information used in such activities. All written reports, records or any work product or communication related to quality improvement activities are considered privileged and confidential information. Except when specific reference is necessary to meet the goals of the QM program, reference to individual providers or members are redacted to safeguard the person’s identity.
Periodic re-training efforts reinforce the importance of confidentiality. All members and providers who participate on ValueOptions’ committees must also demonstrate their understanding of ValueOptions’ confidentiality policies and procedures by signing confidentiality statements prior to committee participation. Participating provider contracts are explicit in regard to treatment record confidentiality requirements.