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Quality Reviews & Tips For Behavioral Health Providers

Date: 04/16/18

The National Committee for Quality Assurance (NCQA) defines the Healthcare Effectiveness Data and Information Set (HEDIS) as a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of health plans.

Why HEDIS Is Important

  • It ensures that health plans are offering quality care and service to members.
  • It helps providers like you effectively monitor care, prevent complications and identify potential issues related to non-compliance.
  • It supports members in making informed decisions about their health and healthcare.

To ensure that our behavioral health members are receiving quality-driven care, we conduct several quality reviews. Here’s what behavioral health providers need to know about these reviews:

Provider Quality Monitoring

Per the Louisiana Department of Health (LDH), we will be conducting medical record reviews (MRRs) to confirm compliance with Clinical Practice Guidelines on three levels of care:

  • Inpatient/residential
  • Outpatient
  • Substance Abuse

What To Know:

  • Audits will be conducted randomly throughout the year based on services provided to our members.
  • Providers will be notified in advance.

Prescription Monitoring Program (PMP)

Per LDH, we conduct random, annual audits to ensure that providers are consulting the PMP prior to prescribing a controlled substance to a behavioral health member. This applies to first fills of controlled substances. Providers must check the PMP and print the findings, then file the findings in the behavioral health patient’s chart to ensure compliance.

What To Know:

  • A first fill is defined as any medication that has not been filled within a 90-day period.
  • Documentation should be filed both initially and annually.

Adverse Incident (AI) Reporting

All healthcare providers are required by the state to report Adverse Incidents to the patient’s Medicaid health plan using the AI Reporting form. Incidents must be reported within one business day of the discovery of the incident. All MCOs use the same reporting form. Our form is located here on our website.

What To Know:

  • We are monitoring providers to ensure compliance with the state’s reporting requirements.
  • We provide free Adverse Incident training to all providers as well as many other free training and educational opportunities. Click here to learn more.

Ensuring Medication Availability

One of our key quality initiatives for 2018 is making sure that behavioral health patients receive their medications in a timely manner upon discharge from a hospital. Medications should cover the intervening days until the first scheduled psychotropic after-care appointment.

What To Know:

  • Discharge planning should address the availability of and access to prescribed medications in the patient’s community.
  • If your patient has been discharged from the hospital without access to prescribed medications, contact our Pharmacy Case Management team.