Quality Improvement

Program Purpose

CareSource is committed to providing evidence-based care in a safe, member-centered, timely, efficient and equitable manner. The scope of our CareSource quality improvement (QI) program is comprehensive and includes clinical and non-clinical services.

CareSource monitors and evaluates the quality of care, encompassing the safety and service delivered to our members with an emphasis on accessibility to care, availability to care, availability of services and physical and behavioral health care delivered by network practitioners and providers. CareSource also monitors the quality and safety of member services through review of practitioner, provider, hospital, utilization management, care management and pharmacy program data.

Member satisfaction and health outcomes are monitored through quality improvement activities, routine health plan reporting, review of accessibility and availability standards, utilization trends and annual Healthcare Effectiveness Data and Information Set (HEDIS®). In addition, Marketplace members complete the annual Quality Health Plan (QHP) Enrollee Survey to capture member perspectives on health care quality. The QHP Enrollee Survey is a consumer experience survey that assesses the enrollee experience with plans offered through Marketplace. The survey includes a set of core questions that address key areas of care and service provided to members.

CareSource is NCQA accredited. NCQA accreditation status shows our commitment to service and clinical quality that meets or exceeds NCQA’s rigorous requirements for consumer protection and quality improvement.

Program Scope

CareSource supports an active, ongoing and comprehensive quality improvement program, including review and resolution of quality-of-care concerns. The scope of the Quality Improvement program includes:

  • Determine interventions for HEDIS overall rate improvement to improve preventive care scores and facilitate support of members’ acute and chronic health conditions and complex needs
  • Advocate for members across settings, including review and resolution of quality of care concerns
  • Meet member access and availability needs for physical and behavioral health care
  • Determine interventions for HEDIS® overall rate improvement that improve preventive care scores and facilitate support of members’ acute and chronic health conditions and other complex health, safety or welfare needs
  • Determine interventions  based on Enrollee QHP results that enrich member and provider experience and satisfaction
  • Demonstrate enhanced care coordination and continuity across settings
  • Meet members’ cultural and linguistic needs encompassing the social determinants of health
  • Monitor important aspects of care to ensure the health, safety, and welfare of members across health care settings
  • Determine practitioner adherence to clinical practice guidelines
  • Support member self-management skills
  • Partner collaboratively with network partners, practitioners, regulatory agencies and community agencies
  • Ensure regulatory and accrediting agency compliance

CareSource Quality Strategy

CareSource seeks to advance a culture of quality and safety that begins with our senior leadership and is cultivated throughout the organization. CareSource utilizes the Institute of Healthcare Improvement (IHI) framework developed to optimize health system performance, as well as the Centers for Medicare & Medicaid Services’ (CMS) National Quality Strategy, which is a national effort to align public and private sector stakeholders to achieve better health and health care.

CareSource aligns with the IHI Triple Aim framework to:

  • Improve the member experience of care (including clinical quality and satisfaction)
  • Improve the health of populations
  • Reduce the per capita cost of health care

CareSource also utilizes Lean Six Sigma tools, when indicated, to focus on improving member experience, member safety and ensuring our processes consistently deliver the desired results.

Quality Measures

CareSource continually assesses and analyzes the quality of care and services offered to our members. This is accomplished by using objective and systematic monitoring and evaluation to implement programs to improve outcomes.

CareSource uses HEDIS® to measure the quality of care delivered to members. HEDIS is one of the most widely used means of health care measurement in the United States. HEDIS is developed and maintained by the NCQA. The HEDIS tool is used by America’s health plans to measure important dimensions of care and service and allows for comparisons across health plans in meeting state and federal performance measures and national HEDIS benchmarks. HEDIS measures are based on evidence-based care and address the most pressing areas of care. Potential quality measures for the Health Insurance Marketplace are:

    • Wellness and prevention
      • Preventive screenings (breast cancer, colon cancer, cervical cancer, chlamydia)
      • Well-child care
      • Immunizations
    • Chronic disease management
      • Comprehensive diabetes care
      • Controlling high blood pressure
    • Behavioral health
      • Follow-up after hospitalization for mental illness
      • Antidepressant medication management
    • Safety
      • Use of imaging studies for low back pain

    Preventive and Clinical Practice Guidelines

    As noted previously, CareSource approves and adopts evidence-based nationally recognized standards and guidelines and promotes them to practitioners to help inform and guide clinical care provided to members

    The use of these guidelines allows CareSource to measure their impact on member health outcomes. Review and approval of the guidelines are completed by the Market CareSource Provider Advisory Committee (PAC). The CareSource Enterprise PAC also approves the guidelines.The Quality Enterprise Committee (QEC) is notified of guideline approval. Topics for guidelines are identified through the analysis of member populations demographics and national or state priorities. Guidelines may include, but are not limited to:

    • Behavioral health (e.g., depression)
    • Adult health (e.g., hypertension or diabetes)
    • Population health (e.g., obesity or tobacco cessation)

    Guidelines may be promoted to providers through one or more of the following: newsletters, our website, direct mailings, provider manual, and through focused meetings with CareSource Provider Engagement Specialists. Information regarding clinical practice guidelines, Patient Safety program and other health information are made available to members via member newsletters, the CareSource member website, or upon request.

    If you would like more information on CareSource quality improvement, please call Provider Services.

    Quality of Care Reviews

    CareSource ensures the provision of safe and quality care to members by investigating and mitigating potential quality of care concerns, that include:

    • Inappropriate or inconsistent treatment
    • Delay in receipt of care
    • Compromising member health, safety or welfare
    • Having the potential to limit functional abilities on a permanent or long-term basis

    In order to properly assess quality of care concerns CareSource Enterprise Quality Improvement initiates contact with providers to request medical records using established processes and timelines. As per our policies and provider contracts, we are authorized to ask for protected health information for health care operations, which includes quality issue reviews. Medical record requests are forwarded to providers via mail, e-mail or fax and may be returned to CareSource via these same mechanisms as detailed in the medical record request document.

    All providers are expected to return medical record requests related to quality-of-care concerns within 14 days from initial receipt of the request, unless otherwise defined by program guidelines or state or federal law requirements. In the event that a state, federal or regulatory agency, or if the health and safety of a member requires that medical records must be submitted under a shorter timeframe, providers are expected to comply with the shorter turnaround time. Providers and facilities that utilize third party health information management vendors are responsible for providing medical records to CareSource or facilitating delivery of medical records to CareSource by the identified contractor. We are legally bound to interact with providers only and CareSource is not subject to any fees charged by health information management companies for medical record retrieval or submission.

    Your health partner representative may contact you if medical records are not received within the 14-day timeframe to ensure you received the request. In addition, our market Chief Medical Officer may also be in contact to facilitate and ensure receipt of the required medical records to complete the quality-of-care reviews. Providers or facilities who repeatedly fail to return requested medical records are reported to the Credentialing Committee and may face other directed intervention or penalties up to and including contract termination.

    CareSource Commitment to Health Equity

    We are dedicated to the communities in which we serve and making a positive impact in the lives of our members by eliminating health disparities, supporting our organization’s Health Equity initiatives, partnering with community stake holders to carry out this much needed work. Our Enterprise Life Services Department is dedicated to serving marginalized communities and making a positive impact in the lives of diverse member populations to eliminate health disparities. Enterprise Life Services is taking an integrated approach to Health Equity and embedding it across CareSource.

    Food & Nutrition:  regular & consistent access to healthy foods, education on nutrition & overall health impacts, addressing food deserts and inequalities

    Health Equity:  pursuit of Health Equity for Black,  Indigenous and People of Color (BIPOC), LGBTQIA, &

    complex populations, elimination of health disparities; partnerships with outside organizations; drive policy & advocate for change

    Patient Safety Program

    Patient Safety Program CareSource recognizes that patient safety is the cornerstone of high-quality health care, contributing to the overall health and welfare of our members. Our CareSource Patient Safety Program evaluates patient safety trends with the goal of reducing avoidable harm. Our patient safety program is developed in the context of our Population Health Management approach and includes:

    • Regulatory/Accreditation
    • Policies & Procedures
    • Training & Implementation
    • Continuous Monitoring
    • Program Evaluation & Improvement

    Safety events are monitored through retrospective review of quality-of-care concerns and real time reporting of Claims data. Data analysis of our provider and health system network ensures situational risks can be identified in a timely manner, reviewed and mitigated by proactive corrective action or performance improvement steps.

    HEDIS Coding Guides

    To ensure HEDIS measures are captured when billing CareSource, please review the following HEDIS coding guidelines for children and adults and use the appropriate ICD-10 and certified procedural terminology (CPT) code:

    Contact Us

    If you would like more information about CareSource Quality Improvement, please call Provider Services Monday through Friday, 8 a.m. to 6 p.m. Eastern Standard Time (EST) at 1-866-286-9949.

    HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
    CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).