HNS is committed to continuous quality improvement and our CQI programs are designed to help assure that network providers are appropriately credentialed and that services provided to subscribers are delivered in the most effective and cost-efficient manner.
The CQI program objectives include working to assure that network providers are properly credentialed, consistent with NCQA and URAC credentialing standards, providing ongoing education, provide a fair and reliable mechanism to monitor and evaluate provider performance, and recommending and implementing actions regarding quality issues with respect to HNS and HNS contracted payor policies and the policies of applicable state licensing boards.
Our CQI program was developed by the HNS Quality Improvement Committee with assistance from our contracted payors. HNS does not delegate any services or functions associated with the HNS CQI Program. Our CQI program is reviewed annually by the CQI Committee and HNS contracted payors. The Program is updated at least annually but as often as required to remain consistent with guidelines established by HNS contracted payors, as well as NCQA and URAC guidelines and applicable state and federal laws.
HNS providers must participate in and abide by all programs established by HNS and/or HNS contracted payors.
The CQI Program includes the following programs:
Credentialing
Comparative Practice Patterns (CPR) Program
HNS Policies
Complaint review and resolution
Continuing Provider Education
HNS Post Payment Reviews
Pre and Post Payment Audit Assistance
NCQA Back Pain Program
Staff and Qualifications
The CQI Committee includes two Chiropractic physicians who serve as the directors of the CQI Program, and committee members who are chiropractic physicians The directors and members of the CQI Committee evaluate the appropriateness and effectiveness of the program, make modifications to the program, establish policies and procedures and monitor provider performance, and assure fair and unbiased data analysis.
All members of the HNS CQI Committee are practicing physicians appropriately licensed by the states in which they practice. Neither the directors nor CQI Committee members receive compensation related to the outcomes of any HNS CQI Program.
Policies and Requirements
The CQI Committee has developed various policies and procedures with respect to the CQI Program including those provided in this document. While network providers must comply with HNS and HNS contracted payor policies, these policies should not be followed if doing so could adversely affect the delivery of appropriate patient care.
The following core HNS policies, established by the CQI Committee, serve as the foundation for many of decisions rendered by the CQI Committee with respect to CQI Programs.
Services provided and billed through HNS should be rendered only by providers appropriately credentialed by HNS.
All services should be delivered in the most effective and cost-efficient manner.
With the exception of maintenance/supportive care, all services provided and billed to HNS contracted payors must be clinically appropriate, medically necessary, consistent with the patient’s chief complaint/ clinical findings, diagnoses and treatment plan.
All services billed through HNS must be properly documented in the patient’s health care record. The provider must assure the accuracy of the type and number of services reported. All services should be reported using the most appropriate CPT, HCPCS and ICD codes.
All services provided and billed through HNS must be consistent with HNS and HNS contracted payor policies, the policies of applicable state licensing boards, as well as applicable state and federal laws.
By signing the HNS Practitioner’s Participation Agreement contracted providers have agreed to comply with all policies established by HNS and HNS contracted payors. Providers who fail to consisently comply with these polices are at risk of termination from the HNS network.
Network providers who fail to adhere to HNS and/or HNS payor policies may be subject to various HNS requirements up to and including probationary status or termination from the HNS network.
Requests for information by HNS, notice of violations of HNS and/or HNS policies, notice of probation status, notice of termination from the network may be communicated via telephone, email, fax, and/or or US mail or commercial carrier. Such notifications will include suspected or actual violations of HNS and/or HNS payor policies.
Probationary Status
HNS may place the provider on “probationary” status with respect to his participation with the HNS network. Probationary status is defined by HNS as the status given to a network provider who has been found to be in violation of one of more HNS and or HNS contracted payor policies and has been given a dfined period in which to demonstrate compliance.
Providers who are on probationary status and do not demonstrate compliance to HNS and HNS policies by the end of their probation period, will be subject to immediate termination from the HNS network.
In most cases, HNS will provide prior written notice of violations that could result in termination from the network; however, HNS and HNS contracted payors reserve the right to terminate a provider's status as a participating HNS provider, at any time, without prior notice.
Terminations of the HNS Practitioner's Participation Agreement
If HNS determines that the HNS Practitioner's Participation Agreement must be terminated, HNS will provide written notice to the provider in advance of the termination date.
Exception: if HNS is unable to locate or communicate with the provider no notice is
required.
With few exceptions, providers have the right to appeal decisions to terminate the HNS Practitioner's Participation Agreement. Information about the HNS appeals process is included on this page. Providers are encouraged to contact HNS with any questions regarding the HNS appeals process.
Appeals to reconsider termination of participation will not prevent the termination of the HNS Practitoner's Participation Ageement. However, appealing a decison to terminate allows the provider an opportunity to present reasons the provider believes that reconsideration should occur. Providers wishing to appeal termination decisions
must follow the HNS appeals process.
Resignation vs. Termination
If a provider has received a notice that his particpation in the HNS network will be terminated,the provider has the option of resigning from the HNS network provided HNS receives the provider's written intent to resign from the network no less than three (3) business days prior to the effective date of the termination stated in the HNS notice of termination. Resignations not received at last 3 business days prior to the stated termination effective date will not be accepted and HNS will terminate participation on the effective date stated in the notice of termination.
Requests for Information/Assistance by HNS
If HNS requests information or assistance from a network provider related to fufulling HNS' intermediary responsbilities, providers must promptly comply with such requests.
If a provider fails to provide requested information, HNS will make two additional attempts to contact the provider to obtain the requested information. These efforts to contact the provider may be via U.S. Mail, telephone, fax or email. HNS will document all attempts, including the date and method of communication. If, after two attempts, the provider does not respond to such requests and/or HNS is unable to communicate with the provider, HNS may take action, including placing the provider on probationary status and/or terminating the provider's participation in the network.
HNS Appeals Process
Network providers who have questions regarding a determination or decision are encouraged to contact HNS. HNS and the CQI Committee will respond to all questions in a timely manner.
Network providers have the right to appeal decisions including termination of participation with the HNS network.
Exceptions: Providers whose participation in the network has been denied or whose participation in the network is terminated due to felony convictions, sanctions issued by the Office of the Inspector General or any actions, including reprimands, by state licensing boards may not be allowed to submit an appeal. In these circumstances, the decision of the Committee is final.
To appeal a determination of the CQI Committee, the Committee must received written notification of the provider’s intent to appeal, within thirty (30) days of the date shown on the HNS notice in which the original determination or decision of the CQI Committee was issued.
Appeals received after 30 days from the date shown on the HNS notice in which the original determination or decision was issued will not be considered. The provider’s written appeal request must include specific, substantive reasons why the provider believes that reconsideration of the decision should occur.
Upon receipt of the written appeal for reconsideration, HNS may request additional information including, but not limited to, copies of specific healthcare records for patients whose health care plans contract with HNS, to be reviewed for compliance to HNS and payor policies and the practice guides issued by the Board of Chiropractic Examiners in the state in which you reside.
If additional information is required, the physician will be notified in writing of the specific information that must be submitted. Any requested information must be submitted to HNS within 30 days of the date of the written request from HNS. If information requested by HNS is not received within 30 days of the date of the written request from HNS, the appeal process will terminate and the original HNS determination will stand.
If additional information is not requested by HNS, HNS will schedule a hearing within 60 days of receipt of the written appeal.
If additional information is requested, HNS will schedule a hearing within 60 days of receipt of the requested information.
All hearings will be held at the HNS offices in Cornelius, NC. The provider will be notified, in writing, of the date and time of the hearing. The provider has the right to be represented at any such hearing by an attorney or any other person of the provider’s choice but may not be accompanied by more than one individual at any such hearing.
During the hearing, HNS will review the basis for the determination and the provider will be afforded an opportunity to explain his reasons for requesting reconsideration and may present any supporting documentation with respect to reconsideration of the decision.
HNS will notify the provider within 30 days of the date of the hearing, in writing, of the decision of the committee. The decisions of the HNS Hearing and Appeals Committee are final.
References:
HNS Practitioner’s Participation Agreement (PPA)
The HNS Practitioner’s Participation Agreement (PPA) establishes that network providers must participate in and abide by such HNS Quality Assurance and utilization programs as may be adopted by HNS.
Section 3.7. of the HNS PPA states:
Compliance with Quality Assurance, Utilization Review, Credentialing and Other Programs and Policies. Participant agrees to comply fully with, and participate in the implementation of, Payors’ policies and programs as described in the applicable Payor Options and any applicable provider manuals. Participant further agrees to participate in and abide by such HNS Quality Assurance, Claims Payment Protocols, and Utilization Review Program(s) (“QA/UR Program(s)”) as may be adopted or implemented from time to time by HNS. HNS shall provide Participant with specific QA/UR Programs as adopted or implemented, upon request. Failure to comply with this provision may be considered grounds for immediate termination of participation with HNS….
…..Furthermore, Participant agrees to cooperate with HNS in all ways reasonably requested by HNS, to comply with all policies, programs, rules and regulations which may be adopted by HNS from time to time, and to accept the recommendations and decisions of HNS.
Section 3.5 of the HNS PPA states:
Administration. Participant agrees to cooperate with, abide by and participate in all administrative policies and procedures that may be established by HNS or a Payor including, but not limited to, those set forth in any policy manual. Participant further agrees to abide by the terms of any and all contractual agreements that exist or may be entered into between HNS and Payors.
Part I – Credentialing
Goals and Objectives
The objective of the HNS credentialing plan is to assure that all network providers have met the high standards established by HNS and our contracted payors, which are consistent with NCQA and URAC credentialing standards for chiropractors.
Credentialing is the initial process through which HNS collects, reviews, and verifies specific criteria and pre-requisites in order to determine a provider’s eligibility for participation with HNS. The HNS Credentialing Plan was established by the HNS Credentialing Committee and is consistent with NCQA and URAC credentialing standards.
Overview of Program
The HNS credentialing program is led by the HNS credentialing committee, under the supervision of the HNS Physician Directors. Consistent with the HNS Credentialing Plan, the HNS Physician Directors and the HNS Credentialing Committee members make all decisions regarding the acceptance or denial of credentialing applications. While HNS contracted payors have delegated the credentialing function of network providers to HNS, all HNS contracted payors reserve the right to approve or deny any applicant for participation in their health care plan.
Providers who are interested in becoming participating providers with HNS should contact HNS and request an application. The credentialing process takes approximately 6 weeks from the date the completed credentialing application packet is received by HNS. The application is reviewed for completeness and the process of verification of information begins. Incomplete applications are returned to the provider with a letter outlining what is needed for the application to be considered complete. For each applicant, HNS will obtain additional information from the appropriate malpractice carrier, the appropriate state licensing board, the National Practitioner Data Bank (NPDB) and the Chiropractic Information Network Board Action Databank (CINBAD) and/or other sources as may be required or indicated.
Providers are notified of the decision of the Credentialing Committee, in writing, within 60 days of receipt of the completed credentialing applications.
Pursuant to the terms of the HNS Practitioner’s Participation Agreement, HNS Network providers must comply with all HNS Credentialing Plan requirements, policies and procedures
The HNS Credentialing Program and Plan are reviewed, updated and approved annually by the HNS Quality Improvement Committee and by HNS contracted payors.
The HNS Credentialing Plan and Policies are posted on this website under the Provider Tab/Credentialing.
Part II - Comparative Practice Patterns Program
Health Network Solutions, Inc.
Comparative Practice Patterns
Review (CPR) Program
The HNS CPR program is designed to help assure that services provided and billed through HNS are delivered in the most effective and cost-efficient manner, and are provided consistent with HNS and HNS payor policies, the policies of applicable state licensing boards and applicable state and federal laws.
The HNS CPR Program does not address the medical necessity of care provided by network physicians; it is a review and statistical analysis of practice patterns and a comparison to the collective practice patterns of the entire HNS physician network.
All health care physicians are expected to provide clinically appropriate care to their patients; however, not all clinically appropriate care may be a covered benefit under a member’s health care plan. The health insurance plan and/or employer groups who purchase insurance plans determine which benefits are covered under a particular plan.
Billing a payor and collecting payment for services not provided or not covered under a member’s health care plan may constitute fraudulent billing practices. Providing services that are not consistent with HNS and HNS payor policies, the policies of applicable state licensing boards and applicable state and federal laws are violations of the terms of the HNS Practitioner’s Participation Agreement.
The HNS CPR Program is posted on the HNS website, www.healthnetworksolutions.net. Click on the “Provider” tab on the home page, then HNS/HNS Payor Policies and then the Quality Improvement/Comparative Practice Patterns Program.
Physicians are encouraged to contact HNS or a member of the HNS Continuous Quality Improvement Committee with any questions regarding the HNS CPR program.
HNS Policy:
HNS network providers must consistently deliver effective, cost-efficient care to members of healthcare plans that contact with HNS. The HNS CPR program utilizes the physician's "average cost per patient" as the metric to evaluate cost-efficiency.
Continued participation in the HNS network requires the consistent delivery of cost-efficient care, as defined by HNS CPR program parameters.
Goals and Objectives:
The HNS CPR program seeks to identify physicians whose statistics indicate over-utilization and to provide assistance and education to those physicians to reduce and prevent inappropriate utilization.
The objectives of the HNS CPR program are to:
Promote the effective and efficient utilization of services by providing meaningful and actionable utilization data to network physicians and through ongoing monitoring of utilization.
Provide ongoing physician education regarding appropriate and cost-efficient use of healthcare resources.
Identify physicians whose data indicates over-utilization and provide assistance and education to those physicians to reduce and prevent inappropriate utilization.
Assure the data utilized is statistically relevant and appropriately collected.
Assure the program parameters are reasonable and accommodate variables that may affect the physician’s utilization and resulting physician participation status.
Assure peer-to-peer data analysis.
Assure fair and consistent decision-making.
Assure timely resolution of identified problems.
Promote the delivery of quality, cost-efficient chiropractic care.
Promote a more efficient health care delivery system.
Staff and Qualifications
The CPR program is led by the directors of the HNS Continuous Quality Improvement Committee, both of whom are practicing chiropractors and appropriately licensed by the states in which they practice. Additionally, all members of the HNS Continuous Quality Improvement Committee are practicing chiropractic physicians appropriately licensed by the states in which they practice.
The HNS Continuous Quality Improvement Committee evaluates the appropriateness and effectiveness of the program, makes modifications to the program, establishes policies and procedures, provides peer-to-peer analysis of data, monitors physician performance and makes decisions relating to the program. Neither the directors nor committee members receive compensation related to the outcome of any HNS Continuous Quality Improvement Program.
HNS CPR Program
The HNS CPR Program was established by the HNS Continuous Quality Improvement Committee and is limited to Doctors of Chiropractic in the HNS network. The Program is reviewed and updated at least annually but as often as required to remain consistent with guidelines established by HNS contracted payors, as well as applicable state and federal laws.
The HNS CPR Program seeks to align incentives between physicians, payors and HNS and, through a reduction in administrative withholds, increases reimbursement for those physicians who consistently deliver effective, cost-efficient care and awards those physicians' practices the special designation of "HNS Center of Excellence".
Summary of HNS CPR Program
In January of each year, HNS conducts an annual review of practice patterns and services provided by each network physician that were billed through HNS.
Annual reviews are based on data obtained from claims submitted through HNS during the previous calendar year.
The HNS software program calculates the physician's "average cost per patient" for the reporting period. Average cost per patient is obtained by dividing the total contracted allowables for the reporting period by the total number of patients treated during the reporting period.
The HNS CPR program utilizes the physician’s average cost per patient as the metric to evaluate cost-efficiency.
A benchmark for “average cost per patient” has been established from data obtained for the total HNS physician population over a period of at least 12 months.
Variations in practice patterns, patient demographics and differences in clinical characteristics impact a physician’s average cost per patient. To adjust for these variations, the HNS Range of Acceptance (ROA) provides a 50% variation from the HNS average cost per patient utilized in the CPR program. Accordingly, average costs per patient within 50% of the HNS network average are within the HNS range of acceptance and are viewed as an indicator of cost-efficient care.
Based on the physician's "average cost per patient" and the HNS range of acceptance for this metric, HNS assigns a "plan ranking" for each HNS contracted health care plan.
The combination of "plan rankings" from the annual review in January determines each physician's HNS Participation Status.
The physician's HNS Participation Status determines his/her HNS administrative withhold for the remainder of the calendar year. With a few exceptions, the HNS Participation Status cannot be changed until the next annual review. (Exceptions noted under “HNS Participation Status”)
Results of the annual review are provided via the HNS Comparative Practice Patterns Report (CPR). CPR’s include the physician's "average cost per patient," compares the physician’s average cost per patient to the HNS benchmark and range of acceptance for this metric, plan rankings, HNS Participation Status and the HNS administrative withhold.
In addition to the annual review, HNS conducts monthly reviews. Each monthly review is based on the most recent 12 months of data.
Continued participation in the HNS network requires the consistent delivery of effective, cost-efficient care. Physicians whose practice patterns are inconsistent with cost-efficient care are placed on Probationary Status and are at risk of termination from the HNS network. Physicians on probation are offered peer-to-peer counseling from a member of the HNS Continuous Quality Improvement Committee and provided a specified time frame to improve their cost-efficiency.
Physicians whose average cost per patient are not within the HNS range of acceptance at the end of the Probationary Period are not allowed to remain in the HNS network.
Physicians may appeal their HNS Participation Status within 30 days of the date the HNS Participation Status is first assigned.
HNS Comparative Practice Patterns Review (CPR)
HNS Policy:
HNS network providers are expected to provide chiropractic care in the most effective and cost- efficient manner.
The HNS CPR program utilizes the physician's "average cost per patient" as the metric to evaluate cost-efficiency.
Continued participation in the HNS network requires the consistent delivery of cost-efficient care, as defined by HNS CPR program parameters.
Average Cost per Patient
The HNS CPR program utilizes the physician's "average cost per patient" as the metric to evaluate cost-efficiency.
Physician's Average “Cost per Patient”
The physician's "average cost per patient" is calculated by dividing the physician's total contracted allowables for the reporting period by the physician's total number of patients for the reporting period.
HNS Network Average "Cost per Patient"
(12 month reporting period)
CPR reports for 12 month reporting periods compare the physician’s average cost per patient to the HNS benchmark for this metric for a 12 month period.
HNS Network Average “Cost per Patient”
(Interim reporting periods for periods of less than 12 months)
CPR reports for interim reporting periods for physicians on Probationary Status compare the physician’s average cost per patient to the HNS actual average cost per patient for the same reporting period.
Risk Adjustment
HNS Range of Acceptance (ROA)
Variations in Practice Patterns
HNS recognizes that many factors impact a physician's "average cost per patient" including, but not limited to, education, variations in practice styles, patient demographics and variations in clinical characteristics, such as severity, co-morbidities and responses to treatment times.
To adjust for these variations, the HNS Range of Acceptance (ROA) provides a 50% variation from the HNS network’s average cost per patient utilized in the CPR program. Accordingly, physicians’ average costs per patient within 50% of the HNS network averagearewithin the HNS range of acceptance and are viewed as an indicator of cost-efficient care.
Plan Rankings for Each Healthcare Plan
Physicians are assigned a plan ranking for each HNS contracted health care plan.
Plan rankings are determined by comparing the individual physician’s “average cost per patient” for each plan to the HNS benchmark for average cost per patient for the same plan. There are 5 plan rankings.
Excellent
Good
Caution
Probation
ID (Insufficient Data)
Plan Rankings within the HNS Range of Acceptance
(Within 51% of the HNS benchmark for average cost per patient)
EXCELLENT
Indicates an “average cost per patient” within 15% of the HNS network average which is within the HNS range of acceptance.
GOOD
Indicates an “average cost per patient” is between 16%- 40% of the HNS network average which is within the HNS range of acceptance.
CAUTION
Indicates an “average cost per patient” is between 41%- 51% of the HNS network average which is within the HNS range of acceptance.
Plan Ranking outside the HNS Range of Acceptance
(Greater than 51% of the HNS benchmark for average cost per patient).
PROBATION
Indicates an “average cost per patient” is greater than 51% of the HNS network average and is not within the HNS range of acceptance.
Plan Ranking “ID” – Insufficient Data
ID – INSUFFICIENT DATA
Although a plan ranking of “ID” indicates limited data relative to a particular health care plan, physicians must assure the delivery of cost-efficient care, regardless of the number of “HNS” patients.
To assist the physician in monitoring practice patterns associated with that plan, the plan ranking includes the comparison of the physician’s average cost per patient to the HNS benchmark for that same plan.
One of the following “ID” plan rankings are shown on the CPR reports:
ID – 0 patients
ID – Excellent
ID – Good
ID – Caution
ID – Probation
HNS Participation Status
By linking increased physician reimbursement to the consistent delivery of effective, cost-efficient care, the HNS CPR Program aligns incentives between physicians and payors. Administrative withholds tied to HNS Participation Status provide financial incentives for physicians to consistently deliver effective, cost-efficient care.
How HNS Participation Statuses are established
The physician’s average cost per patient determines plan rankings for each healthcare plan. The combination of the plan rankings determines the HNS Participation Status. The HNS Participation Status determines the amount of the physician’s administrative withhold. HNS Participation Statuses are assigned in January of each year, based on the previous calendar year's data, and are determined on the lowest plan ranking of all health care plans reviewed.
Simply put:
Physician’s average cost per patient, per plan, determines each plan ranking.
The combination of plan rankings determines HNS Participation Status.
HNS Participation Status determines HNS administrative withhold.
The HNS Participation Status indicates a physician’s cost-efficiency using the same criteria as plan rankings. Each physician is assigned one of the following HNS Participation Statuses.
Note: Plan rankings of ID-Excellent, ID-Good and/or ID-Caution for one or more plans during the reporting period will not negatively impact the HNS Participation Status.
EXCELLENT
Indicates an “average cost per patient” within 15% of the HNS network average (within the HNS range of acceptance) for all plans for which HNS has sufficient data to establish a plan ranking.
In addition to a reduced HNS Administrative Withhold, physicians with an HNS Participation Status of EXCELLENT are included in our performance-based network and receive special designation (above) as an HNS Center of Chiropractic Excellence in payor and HNS physician directories and websites.
GOOD
Indicates an “average cost per patient” between 16%- 40% of the HNS network average (within the HNS range of acceptance) for all plans for which HNS has sufficient data to establish a plan ranking.
CAUTION
Indicates an “average cost per patient” between 41%- 51% of the HNS network average (within the HNS range of acceptance) for all plans for which HNS has sufficient data to establish a plan ranking.
PROBATION
Risk of termination from the HNS network
Indicates an “average cost per patient” greater than 51% of the HNS network average (outside the HNS range of acceptance). Please see page 12 for important information about Probationary Status.
ID – INSUFFICIENT DATA
HNS Participation Status of “ID” is assigned only to those physicians who have a plan ranking of “ID” on all CPR reports. Although a participation status of “ID” indicates limited data for all HNS contracted health care plans, to allow for ongoing monitoring, plan rankings of ID are further categorized to show the comparison of the physician’s average cost per patient to the HNS benchmark for that same plan. One of the following “ID” plan rankings are shown on the CPR reports:
ID – 0 patients
ID – Excellent
ID – Good
ID – Caution
ID –Probation - (Potential risk of network termination)
Despite the limited amount of data, if CPR reports indicate practice patterns inconsistent with the delivery of cost-efficient care, HNS reserves the right, at any time, to change the HNS Participation Status to “PROBATION”, which carries the risk of termination from the network.
Change From Status of “ID”
Unless the HNS Participation Status is changed to probation, as noted above, at such time as there is a sufficient body of data, the HNS Participation Status and HNS administrative withhold will be changed and will be based on the relationship of the average cost per patient for each healthcare plan to the HNS benchmark for each plan.
Combination of all plan rankings
determine HNS
Participation Status
HNS
Participation Status
HNS Administrative
Withhold
HNS
“Center of Chiropractic Excellence” Designation
All plan rankings of "Excellent"
OR any combination of
plan rankings of "Excellent" and/or "ID"
Excellent
7.5%
Administrative Withhold
All plan rankings of "Good"
OR any combination of plan rankings of
"Excellent", "Good" and/or "ID"
Good
8.75% Administrative Withhold
Ineligible
All plan rankings of "Caution"
OR any combination of plan rankings of "Excellent", "Good", "Caution" and/or "ID"
Caution
8.75% Administrative Withhold
Ineligible
ALL plan rankings of "ID"(Insufficient Data)
ID
9.5% Administrative Withhold
Ineligible
All plan rankings of "Probation" OR any combination of plan rankings of “Excellent", "Good", "Caution", "Probation" and/or "ID"
Probation
Risk of Termination from HNS Network
9.5% Administrative Withhold
Ineligible
HNS Probationary Status
An HNS Participation Status of "PROBATION" indicates an "average cost per patient" greater than 51% of the HNS network average and is outside the HNS range of acceptance. Physicians with an HNS Participation Status of PROBATION are at risk of termination from the HNS network.
Plan ranking of ID-Excellent, ID-Good and/or ID-Caution for one or more plans during the reporting period will not negatively impact HNS participation.
Peer to Peer Counseling
Once placed on Probationary Status, physicians are offered additional education and peer-to-peer counseling by a practicing physician who serves on the HNS Continuous Quality Improvement Committee.
Probationary Period
Probationary Status is for a 12 month period and includes an initial period of approximately three months in which the physician is expected to improve his/her average cost per patient to within the HNS range of acceptance.
Interim CPR Reports
During the Probationary Period, physicians will receive interim monthly CPR reports. Interim reports include only data from claims submitted for dates of service during the reporting period. During the 12 month period the physician will receive CPR’s from the date the Probationary Period began.
Improvement during Probationary Period
If, at the end of the initial Probationary Period, the physician’s average cost per patient is within the HNS range of acceptance, the physician will remain on provisional Probationary Status for an additional nine months, until such time as HNS has 12 consecutive months of data indicating a cost per patient within the HNS range of acceptance.
If the physician’s average cost per patient remains within the HNS range of acceptance during the entire 12 month period, at the end of the 12 month period, the physician’s HNS Participation Status and administrative withhold will be changed to reflect the plan rankings for the 12 month period.
Termination from the HNS Network
(No or insufficient improvement during Probationary Period)
If, at the end of the initial Probationary Period, the physician’s average cost per patient is not within the HNS range of acceptance, the physician will not be allowed to remain in the HNS network.
Future Participation
Network physicians are charged with the consistent delivery of cost-efficient care. Once a physician has been assigned an HNS Participation Status of probation, future participation is dependent on them maintaining average costs per patient. Accordingly, a subsequent HNS Participation Status of probation will result in the termination of the HNS Practitioner’s Participation Agreement and the physician will be ineligible to rejoin the network for a period of six months.
Change to HNS Participation Status
With few exceptions, HNS Participation Status cannot change until the next annual review performed in January of the following year.
Exceptions:
Probation
If, at any time, a CPR report indicates a plan ranking of PROBATION, the physician’s HNS Participation Status will change to Probation and the HNS administrative withhold will increase.
ID- Insufficient Data
A status of “ID” indicates for the reporting period the physician has provided care to a relatively small number of patients whose health care plan contracts with HNS. This status does not eliminate the physician’s contractual responsibility to assure the consistent delivery of cost-efficient care to those patients.
Accordingly, if at any time, for any reporting period, CPR’s indicate practice patterns are inconsistent with the delivery of cost-efficient care (i.e. a plan ranking of “ID-Probation) the HNS Participation Status may be changed to “PROBATION” and the HNS Administrative Withhold will be increased.
At such time as HNS has a sufficient body of data, the HNS Participation Status and HNS Administrative Withhold will be changed and will be based on the physician’s average cost per patient for that period of time.
HNS Administrative Withhold (admin fee)
The HNS Participation Status established in January of each year determines the HNS administrative withhold fee for the remainder of that calendar year. Other than the exceptions shown above, the HNS Administrative Withhold will not be subject to change until the annual review performed in January of the following year.
Comparative Practice Patterns Report (CPR)
Results of the HNS Comparative Practice Patterns Review are shared with physicians via the HNS CPR report.
Scope of Reviews
The CPR report is a detailed review and statistical analysis of physician practice patterns. CPR reports provide a review of all services billed through HNS for a specific reporting period. These comprehensive reports identify unusual practice patterns and provide meaningful and actionable utilization data.
Each CPR Report includes:
All CPT/HCPCS codes billed during the reporting period.
A comparison of the physician’s practice patterns to the national averages and the practice patterns of his peers in the HNS network.
The relationship of the physician’s average cost per patient to the HNS benchmark (or, if an interim report, to the HNS actual network average).
The plan ranking for the specific reporting period.
The HNS Participation Status assigned in January based on the HNS annual review.
The HNS Administrative Withhold.
Frequency of Reviews
Reviews are conducted monthly and CPR Reports are provided to each physician, each month, for each HNS contracted healthcare plan.
Monthly CPR Reports
Monthly CPR reports are based on the most recent 12 months of data so plan rankings may change from month to month. For all 12 month CPR reviews HNS utilizes the established HNS benchmark for average cost per patient.
Annual CPR Reports
Annual CPR reports are based on the previous calendar year's data and reflect plan rankings for that reporting period. With only a few exceptions, plan rankings established during the annual review determine HNS Participation Status and the HNS Administrative Withhold for the remaining calendar year. For all 12 month CPR reviews HNS utilizes the established HNS benchmark for average cost per patient.
Interim CPR Reports
Interim CPR reports are provided for physicians on Probationary Status and will reflect data only for services provided during the Probationary Period. For interim reports HNS utilizes the actual HNS network average for cost per patient.
Data on CPR Reports
For physicians who have been in the HNS network a full year, CPR reports will reflect 12 months of data. For physicians in the network less than 12 months, CPR reports will reflect data from claims submitted to HNS since network participation began.
Appeals of HNS Participation Status
Network physicians who have questions regarding a determination or decision are encouraged to contact HNS and/or members of the HNS Continuous Quality Improvement Committee for assistance. If a physician wishes to appeal the HNS Participation Status, the physician must notify HNS, in writing, within 30 days of the date shown on the CPR report generated from the annual CPR, or if the HNS Participation Status changed during the year, within 30 days of the date shown on the CPR report in which the new status was assigned. The written notice must include the reasons why the physician believes reconsideration of the HNS Participation Status should occur.
Upon receipt of the written notice of appeal of the HNS Participation Status, HNS will change the physician's status to "pending review" until the HNS Continuous Quality Improvement Committee completes a review, a hearing is held and a final determination has been made.
Upon receipt of the written appeal for reconsideration, HNS may request additional information including, but not limited to, copies of specific healthcare records for patients whose health care plans contract with HNS.
If additional information is required, the physician will be notified in writing of the specific information that must be submitted. Any requested information must be submitted to HNS within 30 days of the date of the written request from HNS. If information requested by HNS is not received within 30 days of the date of the written request from HNS, the appeal process will terminate and the original HNS determination will stand. If additional information is not requested by HNS, HNS will schedule a hearing within 60 days of receipt of the written appeal. If additional information is requested, HNS will schedule a hearing within 60 days of receipt of the requested information.
All hearings will be held at the HNS offices in Cornelius, NC. The physician will be notified, in writing, of the date and time of the hearing. The physician has the right to be represented at the hearing by an attorney or any other person of the physician’s choice but may not be accompanied by more than one individual.
During the hearing, HNS will review the basis of the determination and the physician will be afforded an opportunity to explain his/her reasons for requesting reconsideration and may present supporting documentation with respect to reconsideration of the determination.
Within 30 days of the date of the hearing, HNS will notify the physician, in writing, of the decision of the committee regarding reconsideration. The decisions of the HNS Continuous Quality Improvement Committee are final.
Based on the outcome of the hearing and appeal process, within 15 days following the hearing, the physician’s HNS Participation Status will be modified from "pending review" to the appropriate participation status and corresponding HNS administrative withhold.
Part lll – HNS Practice Policies
High standards for documentation, coding, billing and compliance have been established for all healthcare professionals. To assist in meeting these high standards and to help you protect your practice, the HNS Practice Policies were created by our Continuous Quality Improvement (CQI) Committee and were developed in part from requirements established by our managed care partners, recommendations from CMS, as well as recommendations issued by the ACA.
HNS and most HNS contracted payor policies are posted on this website under the provider tab, then under HNS/Payor policies, or are posted elsewhere on this website.
By signing the HNS Practitioner’s Participation Agreement, contracted providers have agreed to comply with all policies established by HNS. Providers who fail to abide by HNS and HNS contracted payor policies risk termination from the HNS network.
While all policies issued by both our managed care partners and HNS are expected to be followed by HNS participating providers, these policies are not intended to be used if such use could adversely affect the delivery of patient care.
Physicians should always provide appropriate care to their patients, however, not all clinically appropriate care is covered under a member’s health care plan, and only benefits covered under a member’s health care plan should be billed to HNS contracted payors.
HNS core policies:
Services provided and billed through HNS should be rendered only by providers appropriately credentialed by HNS.
All services should be delivered in the most effective and cost-efficient manner.
With the exception of maintenance/supportive care, all services provided and billed to HNS contracted payors must be clinically appropriate, medically necessary, consistent with the patient’s chief complaint/ clinical findings, diagnoses and treatment plan.
All services billed through HNS must be properly documented in the patient’s health care record.
Prior to reporting services provided, the provider must assure the accuracy of the type and number of services reported and all services should be reported using the most appropriate CPT, HCPCS and ICD codes.
All services provided and billed through HNS must be consistent with HNS and HNS contracted payor policies, the policies of applicable state licensing boards, as well as applicable state and federal laws.
PART IV - Allegations/Complaints review and resolution
HNS is charged with complaint review,investigation and resolution for all allegations/complaints involving network providers. Allegations/complaints may originate from a contracted payor, a patient, an employee of the provider of other sources.
All allegations/complaints will be communicated to providers via email, telephone, fax and/or US mail or commercial carrier. Network providers must cooperate in the timely resolution of all complaints or allegations. If information is requested by HNS, providers must promptly respond to such requests.
If HNS' review indicates the provider has violated HNS and/or HNS policies, state and/or federal statutes and or applicable state regulations, HNS may take
the following actions. Failure to respond promptly to requests from HNS may result in termination from the HNS network.
1. Require
the provider to submit a signed attestation statement indicating he/she has read,
understands and agrees to comply with HNS and HNS payor policies or laws or regulations.
2. Require the submission of a
written corrective action plan.
3. Require the submission of copies
of patient healthcare and financial records.
4. Require the provider to obtain
additional continuing education
5. Place the provider on probationary
status
6. Terminate the Provider's
Practitioner's Participation Agreement
7. Other
such actions as deemed appropriate by the HNS Quality Improvement Committee (CQI).
Part V – Continuing Provider Education
HNS is committed to ongoing provider education and we strive to provide meaningful education both from a clinical perspective as well as with respect to proper documentation, coding, billing and compliance issues.
HNS offers free continuing education on our website, through seminars held throughout the year, and in conjunction with chiropractic associations in various states. HNS will notify all providers in advance of our free seminars.
HNS has also developed and distributed the HNS Practice Protection Plan, a manual that includes HNS and HNS policies and the policies of applicable state licensing boards. This manual was developed by the CQI Committee with assistance from our managed care partners, in an effort to provide much of the information needed for compliance in one manual for easy reference. This manual is updated as needed and is available to all providers and their staff members.
PART VI – HNS Post Payment Reviews
Our CQI Program includes post payment reviews of network provider’s health care records.
HNS takes an educational rather than a punitive approach with respect to post payment reviews initiated by HNS CQI Committee. This program was designed primarily to provide ongoing education and assistance for our network providers with respect to proper documentation, coding, billing and compliance to HNS and HNS payor policies and the policies of appropriate state licensing boards as well as compliance to state and federal laws.
Once reviews are complete, providers receive a written report from the CQI Committee identifying specific existing or potential problem areas and include recommendations for improvement. Providers whose healthcare records fall short of requirements may be required to obtain 4 hours of board-approved continuing education in documentation and compliance. HNS provides a free 4 hour board-approved CE program on the HNS website that can be utilized to meet this requirement. This web based continuing education is presented by a leading expert in the area of chiropractic documentation and coding. Providers whose reviews indicate significant problem areas may be subject to subsequent reviews.
Additionally, such providers may be required to submit a written correction action plan with respect to improving the problem areas identified in the review. Providers will be given appropriate time to implement policies and procedures included in their action plans and are advised that a subsequent audit will be performed. Providers are also advised via written notification that should subsequent audits reveal continued areas of non-compliance, they are at risk of termination from the network.
While the initial review is intended for educational purposes, if subsequent audits reveal continued non-compliance to HNS and HNS payor policies and/or the policies of applicable state licensing boards, with few exceptions, the provider will be terminated from the network. However, HNS will make every effort to educate and assist the provider with respect to proper documentation and compliance in order to avoid termination.
While the initial audits are undertaken from an educational perspective, if evidence of fraud is found during the audit of any network provider, that information is reported to the appropriate state licensing board, HNS contracted payors, Cin-bad and NPDB and the provider will be terminated from the HNS network.
PART VII – Pre and Post Payment Audit Assistance Program(PPAAP)
The PPAA Program was designed by the CQI Committee to provide guidance and assistance to providers undergoing a payor pre or post payment review.
Our CQI Committee will provide assistance to any network provider throughout the entire audit process. The Committee has developed a comprehensive HNS Pre and Post Payment Review Provider Check List to provide step by step guidance throughout the audit review process.
Additionally, a member of the CQI Committee will immediately perform an initial review of the health care records requested by the payor to assist in identifying potential problem areas before you release your records to the payor. We will also review your utilization patterns for claims filed to that payor and provide you with the utilization data that may be pertinent to the audit. Members of the CQI Committee will work closely with you and the payor throughout the audit process in an effort to assure a fair determination is made by the payor.
PART VllI– NCQA Back Pain Recognition Program
The National Committee for Quality Assurance (NCQA) announced the creation of the Back Pain Recognition Program (BPRP), which seeks to recognize physicians and chiropractors who deliver superior care to the approximately 30 million Americans who suffer from low back pain. The program is designed specifically for treatment of an episode of low back pain. Eligible participants include:
Chiropractors Orthopedic Surgeons
Primary Care Physicians Doctors of Osteopathy
The goal of the program is to promote a high-value, patient-centered model of care that includes: comprehensive patient assessment and reassessment, discerning use of imaging, patient education and shared decision-making (for surgeons). The BPRP is the first independent effort to systematically evaluate back pain care.
According to the NCQA, this type of program is the future of healthcare programs and, as such, managed care companies are already eagerly awaiting the results of this new program. The NCQA suggests that managed care organizations may steer patients to NCQA recognized providers.
The HNS CQI Committee is committed to the success of this program and believes that it may provide significant benefit to the chiropractic profession and to our contracted payors and we urge all network providers to participate in this important program.
Many of our HNS providers have already completed the program requirements and received recognition from the NCQA, including the providers who serve on our CQI Committee. Many more are in the process of completing the program. These providers indicate that there is commitment of time involved to complete this program yet stress that the time and effort are well worth this national recognition.
BCBSNC and CIGNA HealthCare support this program and recommend their participating providers seek to achieve this high recognition. Additionally, BCBSNC providers who have achieved this recognition are noted with a special designation in the provider directory on the BCBSNC website.
To learn more about receiving BPRP recognition from the NCQA, please click here:
ADL Forms 
quality improvement / Utilization management (UM) 
