We conduct an analysis of clinical, quality and health outcomes to identify potential variations in care delivery to support the best quality care and outcomes for our members. By comparing data, that is risk-adjusted when appropriate, identifying variations from peer benchmarks and sharing that information with you, we can work collaboratively to improve value for our members.
Together we get a clearer picture of measures that may provide opportunities for improving quality and care experiences for our members. We account for standards of care, evidence-based guidelines and Choosing Wisely® recommendations from the American Board of Internal Medicine Foundation, supported through partnerships with more than 70 national medical specialty societies. Any changes to care programs not previously communicated to the Delegation Oversight Committee should be raised during annual review.
Performance measurement supports practice improvement and provides delegates with access to information regarding how their group compares to peers benchmarks for specific measures. This information provides a starting point for an ongoing dialog regarding how we may best support your efforts to provide high-quality, cost-effective care to our members.
- Delegate performance domains include:
- Clinical UM.
- Clinical quality including STARS, HEDIS and member satisfaction.
- Encounter data performance management.
- Credentialing performance management.
- Financial performance management.
- Compliance with UnitedHealthcare, federal and state requirements.
Performance domains are evaluated regularly, compared to peers benchmarks, and communicated to the delegate in performance reports.
Improvement Action Plans
We may require the delegate to develop an improvement action plan designed to bring the delegate into compliance with performance standards.
Delegates who do not achieve compliance within the established timeframes may require continued oversight until they achieve compliance.
Continued non-compliance or failure to perform may result in removing the delegate from the services.
Notification of Platform Transitions or Migrations
During our initial review of a delegate’s operational capabilities, we also review the delegate’s information systems or transaction platforms in order to validate their ability to comply with our operational and regulatory requirements and connectivity standards. Therefore, we request the delegate provide at least 120 days advance written notice to their UnitedHealthcare delegation oversight representative and their UnitedHealthcare contract administrator or provider advocate of the intent to either:
- Change administrative platform(s) for impacted delegated function(s), including migrations, version upgrades, or conversions, or
- Make material changes in existing administrative platforms that might impact delegated functions.
If you are unsure of what a material change is, please contact your delegation oversight representative.
Please note, some changes may require pre-cutover evaluation and testing by the UnitedHealthcare delegation oversight team(s) to ensure continued compliance with all regulatory compliance and data sharing capabilities.