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Provider Quality Improvement

Building Trusted Partnerships with Providers and Members

Welcome to the Quality Improvement (QI) Corner! A major focus of the QI Program is to continuously improve the quality of care and service provided to our members. In an effort to promote and encourage utilization of Health Net's QI Program, providers can access the QI Corner, a centralized location for current best practices. The QI Corner includes tools and resources that will help you improve:

  • Access to care
  • Coordination of care
  • Communication between provider and patient
  • Patient safety
  • Depression management

Health Net encourages you to utilize the tools that are right for your office or organization. Please remember that small steps towards improving quality can make a huge difference! For questions about the QI Corner and its content, please contact us.

Quality Improvement & Health Equity Program Reports

  • Quality Improvement (QI) and Health Equity Annual Reports
  • Quality Improvement and Health Equity Committee Activities
  • Community Reinvestment Plan
  • Community Reinvestment Report
  • Member Satisfaction Survey Results (Consumer Assessment of Healthcare Providers and Systems (CAHPS))

Featured Topics

Provider Resources

Provider Education

Regulatory Information

Health Net wants members to experience the highest quality of care from the physicians and other providers in its network. To that goal, Health Net recognizes the importance of collaborating with, and supporting, providers in their efforts to improve member's health and meet Medicare's quality standards for our Medicare Advantage (MA) plans.

Quality improvement is a major initiative for the Centers for Medicare and Medicaid Services (CMS). CMS uses the Medicare Five - Star Quality Rating System to monitor the performance of MA health plans to ensure they meet quality standards. For MA members, the ratings provide a tool to compare the quality of care and customer service offered by different MA plans. Providers have a direct impact on over 60 percent of the measures that are used for these ratings.

The rating for the quality of medical services includes multiple measures that fall into the following five categories.

  • Staying healthy – Measures whether members received various screening tests, vaccines and other checkups that help them stay healthy.
  • Managing chronic conditions – Measures how often members with different conditions received certain tests and treatments that help them manage their condition.
  • Member experience with the health plan – Includes ratings of member satisfaction with the plan.
  • Member complaints and changes in the health plan's performance – Measures how often Medicare found problems with the plan and how often members had problems with the plan. Also measures the plan's performance over time.
  • Health plan customer service – Measures how well the plan handles member appeals.

Provider's participation and assistance in providing the highest quality of care to Health Net members is vital to meeting CMS' expectations in the delivery of care to MA members. In an effort to accomplish this goal and meet CMS standards, Health Net has developed tools for provider's use. Please click on the links in the sections below to access these tools.

For up-to-date Provider Tip Sheets refer to HEDIS Measures & Billing Codes.

Toolkit

These resources provide education and support to clinical staff and other provider office staff for improving quality perinatal care and birth outcomes.

Supporting Safe Deliveries

Provider Webinars

March 2018 – Dr. Elliott Main, Medical Director and Executive Committee Chair of the CMQCC is the presenter. Topics include: The importance of supporting vaginal birth and reducing NTSV cesarean rates, How to get involved in CMQCC and join the Maternal Data Center, Potential collaborations with other providers to help implementation at your site.

April 2018 – L. Jeanine Arndal, MD, FACOG, of Northern Inyo Healthcare District is the presenter. Northern Inyo was on the Smart Care Initiative Hospital C-Section Honor Roll for the past two years. Topics include: Discussion of practices to prevent the first cesarean section, Preterm premature rupture of membranes (pPROM), Unique hospital practices, Results and continued work.

Decreasing NTSV Cesarean Section Rates: Putting it into Practice (PDF)

Smart Care California Resources on Improving Maternal Care

2019 Hospital C-Section Honor Roll Recipients (PDF)

Relevant Articles and Case Studies

Improving Perinatal and Postpartum Care

These resources provide education and support to clinical staff and other provider office staff for improving quality perinatal care and birth outcomes.

Additional webinars

September 2018 – Dr. Jack Klein, Clinical Solutions Consultant and Clinical Professor of OB/GYN at Washington University School of Medicine is the presenter. Topics include: Defining Opioid Use Disorder, Effects of Opioid Use on Pregnancy and Pregnancy Outcome, Antepartum, Intrapartum, Postpartum Care and Role of the Obstetrician–Gynecologist and Other Obstetric Care Providers.

Maintaining continuity in patients' medical care is critical following discharge from the hospital to ensure successful recovery. Poor coordination of care across settings can result in costly, potentially harmful, and often avoidable re-hospitalizations. Poor care transition, failures in communication between providers, lack of patient and family involvement and few standardized tools and processes can all contribute to adverse events or avoidable readmissions. Evidence suggests improving core discharge planning and transition processes out of the hospital may reduce the rate of avoidable re hospitalizations.

The materials in this toolbox outlines best practices and provides easy-to-use tools and resources to help hospitals improve or redesign care processes to reduce avoidable hospital readmissions that occur within 30 days of discharge.

Medication Self-Management Review

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation (PDF)

Discharge Planning

Patient Engagement

Tools and Links

Programs for all Members with Diabetes

Health Net's program provides a health management solution to improve the health and quality of life for Health Net members. Through personalized interventions and contemporary behavior change methodologies, Health Net's experienced staff can assist members at risk and diagnosed with chronic health conditions to better manage their conditions through education, empowerment, and support. This program includes clinical management that encompasses health and wellness, disease management, case management, and women's and children's health.

The disease management program provides support to members with chronic conditions, including diabetes. Disease management helps increase the efficiency and effectiveness of care, leads to more timely actions by the member, and helps develop more personalized and actionable solutions that ultimately lead to improved health outcomes. Program information is available in the Provider Library.

Encourage the Importance of Well-Woman Screenings

Between family, work and community responsibilities, women are often so busy caring for others that they overlook their own health needs. Health Net encourages you to remind all women about the importance of regular well-woman screenings to increase early detection and treatment of disease. Physicians play a powerful role in motivating their patients to seek regular health care services.

2020 Adult Preventive Health Guidelines (PDF)

Breast Cancer

Mammograms typically should begin at age 40 for women at normal risk. According to the American Cancer Society (ASC), the following recommendations for breast cancer screening include:

  • Breast examination by a health care provider every three years starting at age 20; annual clinical breast exam starting at age 40
  • Annual screening mammography starting at age 40 or 50. Breast cancer experts do not all agree. When a woman reaches age 40, a mammogram is a personal decision between her and her doctor
  • Women in high-risk categories should have mammograms every year and typically start at an earlier age. MRI or ultrasound screening can also be given in addition to mammograms

Cervical Cancer

The American Congress of Obstetricians and Gynecologists (ACOG) recommends that cervical cancer screening begin at age 21 (regardless of sexual history). Screening before age 21 should be avoided because it may lead to unnecessary and harmful evaluation and treatment in women who are at very low risk of cancer. The ACOG also states:

  • Pap smears are recommended every two years for women between ages 21 and 29
  • Women ages 30 and older who have had three consecutive negative Pap smears and have no history of cervical intraepithelial neoplasia (CIN) 2 or CIN 3, are not HIV infected, are not immunocompromised, and were not exposed to diethylstilbestrol in utero may extend the interval between examinations to every three years
  • Some women at higher risk for cancer may need Pap smears more often to monitor their health

Bone-Density Testing

Bone-density testing typically should start at age 65 and be administered every two years or more frequently as determined by the physician. According to National Osteoporosis Foundation guidelines, there are several groups of people who should consider bone-density testing:

  • All postmenopausal women under age 65 who have risk factors for osteoporosis
  • Postmenopausal women with fractures. This is not mandatory because treatment may well be started regardless of bone density
  • Women with medical conditions associated with osteoporosis. A primary care physician can assess the patient's risk profile for osteoporosis
  • Women whose decisions to use medication might be aided by bone-density testing

Colorectal Cancer

Colorectal cancer screening typically should start at age 50. According to the American College of Gastroenterology, colorectal screening should continue as follows:

  • Colonoscopy every 10 years
  • Alternate strategy of annual stool test for blood and a flexible sigmoidoscopic exam every five years or a double-contrast barium enema every five years

Chlamydia

Chlamydia testing normally starts at age 24 or younger. The U.S. Preventive Services Task Force (USPSTF) recommends Chlamydia screening for:

  • All sexually active women ages 24 or younger
  • Women older than age 24 with high-risk sexual behaviors
  • Pregnant women in the first trimester and again in the third trimester if high-risk sexual behaviors are reported. Treating a pregnant woman who has a Chlamydia infection can prevent an infection in her newborn
  • Women with pelvic inflammatory disease (PID)
  • Women with symptoms of a cervical infection (cervicitis) found in a pelvic exam
  • A newborn whose mother had a Chlamydia infection at the time of delivery
  • If you would like to request a hard copy of the well woman screening pad, please email your requests to the Health Net Quality Improvement Department.

Approximately one third of community dwelling adults over the age of 65 report experiencing a fall in the past 12 months. Many of these falls result in significant injuries such as fractures and head injuries, reduced quality of life and mortality. In addition, the annual direct and indirect costs of fall injuries are expected to reach 54.9 billion by 2020.

Multiple studies have validated that interventions such as encouraging physical exercise, performing medication reviews and correcting environmental hazards can have a positive impact on fall management. The American Geriatric Society has published the Clinical Practice Guideline: Prevention of Falls in Older Persons with recommendations for screening, assessment and interventions. This and additional materials on Fall Risk Management including patient education brochures from the CDC and National Council on Aging (NCOA) are provided as a resource for providers. Please use the presentation and materials below to learn more about this important public health issue and incorporate fall prevention into standard office practice.

Patient Materials

Additional Resources

The Department of Health Care Services (DHCS) requires all new Medi-Cal members complete their comprehensive Initial Health Appointment with a provider within the primary care setting within 120 days from plan enrollment. The Initial Health Appointment (IHA) can be completed by a primary care physician (PCP), nurse practitioner, certified nurse midwife, or physician assistant. At a minimum, it must include:

  • Physical, social, or mental health histories.
  • Preventive care services.
  • Physical examination.

The IHA is required by DHCS for all newly enrolled patients, including those with disabilities. Providers must follow DHCS requirements for completing the IHA, in accordance with DHCS Plan Letters 08-003 and 13-001.

Additional information on IHA Requirements for Medi-Cal Patients

Provider News:

Provider Tip Sheets:

Provider webinar training

The Department of Health Care Services (DHCS) requires that all providers who conduct periodic health assessments on Medi-Cal children provide the following:

  • Verbal or written anticipatory guidance to child's legal parent or guardian of the harmful effects of lead exposure for children starting at ages six months to 72 months (6 years). At a minimum, the information should include that:
    • Children can be harmed by lead exposure from old or chipping lead-based paint and dust.
    • Children that begin to crawl until 72 months of age, are particularly at risk.
  • Blood lead level testing (finger stick or venous blood draw) on children:
    • At 12 months and 24 months of age.
    • If child between ages 12-24 months have no record of lead testing.
    • If child between ages 24-72 months is missing a lead test at 24 months or after.
    • When requested by child's parent or guardian.
    • When provider conducting Periodic Health Assessment (PHA) for child 12-72 months is aware of increased risk of lead exposure/poisoning due to changes in child's circumstances.

Providers must follow the California Department of Public Health Guidelines (PDF) for interpreting blood lead levels and follow-up activities for elevated blood lead levels.

  • Screening for elevated blood levels can be conducted by finger stick test or via venous blood draw.
  • Confirming or retesting of blood lead levels should be conducted through the venous blood test.

Tools to help you complete lead screenings

Health Net provides the following tools to help providers identify children who need a lead test.

If you are not receiving your care gap reports, reach out to your provider representative for information on obtaining or how to review these reports.

Submit codes as evidence of lead testing

Providers can use the following codes for submitting claims/encounters as evidence for lead testing:

Encounter Description Codes1
Venous blood collection CPT 36415
Capillary blood collection CPT 36416
Lead test CPT 83655
Abnormal lead level in blood ICD-10 R78.71
Toxic effect of lead and its compounds, accidental (unintentional), initial encounter ICD-10 T56.0X1A
Toxic effect of lead and its compounds, accidental (unintentional), subsequent encounter ICD-10 T56.0X1D
Toxic effect of lead and its compounds, accidental (unintentional), sequela ICD-10 T56.0X1S
Encounter for routine child health examination without abnormal findings ICD-10 Z00.129
Encounter for screening for disorder due to exposure to contaminants ICD-10 Z13.88
Contact with and (suspected) exposure to lead ICD-10 Z77.011

Providers and labs must report all lead test results to the Childhood Lead Poisoning Prevention Branch (CLPPB). Contact EBLRSupport@cdph.ca.gov.

Exceptions to providing a lead screening

Providers are not required to perform lead screening if:

  • Legal parent/guardian refuses the lead screening and signs a voluntary refusal statement.
  • In provider's professional judgement, lead testing poses greater risk for child than lead poisoning.

Providers must document reasons for not providing the lead screening or not obtaining the voluntary refusal statement in the child's medical record.

Education you can share with your patients

Additional information on Lead Screening Requirements for Medi-Cal Patients

Health Net Provider News

Department of Health Care Services: APL 20-016 Blood Lead Screening of Young Children – English (PDF)

Last Updated: 04/17/2024