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USA is concerned about provider and network performance and has created a grievance policy. This policy was developed to ensure all issues or quality concerns are reviewed and addressed by leaders of our organization. The quality of healthcare comes first and USA will do its best to resolve any such issues brought through this grievance policy. Here it is...
Policy
To promote quality improvement within network services, USA Managed Care Organization shall maintain a system to receive network participant complaints, problems, or suggestions. Any grievance dealing with medical appropriateness or quality of care will be forwarded to USA MCO`s Medical Review Committee consisting of network practitioners, client leaders and key USA MCO staff. All complaints dealing with a network performance issue will also be forwarded to USA MCO`s Medical Review Committee. All complaints dealing with claim disputes will be forwarded to USA MCO`s Claims Liaison Department.
Quality of Care Issues
The Medical Review Committee will objectively and systematically monitor all patient grievances that deal with quality of care and medical appropriateness. The committee will monitor, evaluate and recommend action toward these complaints based on established criteria. The QA committee will be led by USA MCO's medical director and will meet monthly to review all grievances relating to medical appropriateness and quality of care. A written response will be generated following each Medical Review Committee meeting. Filing a Quality of Care Grievance.
Network Performance Issues
USA MCO's Medical Review Committee will also evaluate all other participant issues. The committee serves as a forum for sharing, communicating and recommending improvement efforts based on the suggestions of our network participants. All participant grievances will be addressed with a written response detailing actions taken regarding the complaint. The participant shall receive the response within 30 days of the original complaint. Customer Service will work in conjunction with Provider Relations to address and resolve all participant issues. All complaints will be recorded and kept on file with the Provider Relations Department of USA MCO. Records of complaints will be maintained for a period of two years. This includes the original written complaint, all complaint forms, and an annual report summary of all resolved and unresolved complaints. The Medical Review Committee will review and analyze the nature of participant grievances in order to plan, implement, evaluate, and communicate performance improvement and ethical performance. A participant may appeal directly to the Medical Review Committee if he or she feels that their complaint has not been appropriately responded to. Filing a Network Performance Grievance.
Claim Dispute Issues
In the event of a claim dispute or discrepancy, whether it is a payment, billing or repricing issue, the participant should immediately contact the Claims Liaison Department of Client Services Division in the Phoenix Office.
Upon notification, the Claims Liaison staff will request all pertinent documentation relative to the dispute from the participant (Provider, Payor or Participant). Information gathered will include: patient's name, date(s) of service, provider name, amount of billing/repricing and procedures rendered by participant together with all facts surrounding the inquiry.
As each dispute will vary, each will be processed on an individual basis. The Claims Liaison staff will review all participant contracts (Provider or Payor), together with a review of the claim as billed by the participant. The Claims Liaison staff will further analyze the nature of the participant dispute in order to plan, implement, evaluate, and work with the participants toward resolution of the dispute to the satisfaction of all concerned parties.
Once the resolution to the dispute has been reached, Claims Liaison is responsible for amending or adjusting any repricing or billing statements that are affected by the resolution. Claims Liaison will notify all USA MCO departments or divisions that may be affected by this dispute or the resolution thereto. Copies of all amended repricing statements will be provided to the participants (Provider or Payor) for their records. The participant's month-end billing will reflect all adjustments made to their account resulting from the dispute resolution. All information pertaining to the dispute and resolution are kept on permanent file in the Claims Liaison Department. If the dispute cannot be resolved to the satisfaction of all parties within a reasonable period of time, either party may submit said dispute to Arbitration under the terms of their contract. Notification of Claims Dispute.
