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2014 Annual Quality
Improvement
Program Review
Blue Cross of Northeastern Pennsylvania
is committed to improving the health
of our members by delivering quality,
cost-effective and accessible health
care services while building effective
partnerships with our customers. Our
Quality Improvement (QI) Program
committees monitor and evaluate
outcomes of care and services and then
plan interventions that will continuously improve
the level of care and service provided to our members.
Oversight of the QI Program is performed by the Health Plan’s Quality Improvement committees.
These committees are made up of Blue Cross of Northeastern Pennsylvania employees, representatives
from the board of directors, local medical and behavioral health practitioners, as well as other
service providers. The committees report, on a regular basis, to the board of directors. Each year the
QI Program is evaluated to review the clinical and service activities that the health plan undertakes
to improve health outcomes and member access to benefits and services. The evaluation is used to
identify further actions and opportunities to improve the care and services available to our members.
2014 QI Program Accomplishments
• Maintained health plan quality accreditation with the National Committee for Quality
Assurance (NCQA) for the First Priority Health® HMO and First Priority Life Insurance
Company® PPO and EPO products
• Maintained NCQA disease management quality accreditation for the Blue Health
SolutionsSM chronic disease health management programs*
• Maintained Utilization Review Accreditation Commission (URAC) Accreditation for the Blue
Health Solutions case management program*
• Targeted clinical quality improvement initiatives for breast cancer screening, diabetes,
hypertension, colorectal cancer screening, emergency room (ER) utilization, medication
adherence and follow-up after a behavioral health hospitalization and the appropriate use
of antibiotics and HPV vaccines for adolescents
• Targeted clinical quality improvement for CHIP membership for ER utilization and lead
screening
• Targeted clinical quality improvement activities addressing the needs of the Blue Cross
of Northeastern Pennsylvania behavioral health population
• Development of Patient Centered Medical Home and Provider Quality Program initiatives
to enhance clinical outcomes and coordination and continuity of care for members
• Improved knowledge of safe practices through collaborative initiatives with physicians and
hospitals, and member educational articles
* Accreditation for Blue Health Solutions’ Care Management and Health Management programs are through AllOne
Health Management Solutions®.
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Continued to identify opportunities to improve member and provider satisfaction:
• Implemented virtual hold call back functionality: Allows members to schedule call
backs from Interactive Voice Response (IVR)
• Enhancements to the Member Self-Serve portal which include enhanced benefit displays,
deductible and visit accumulators, claims activity, member dashboard and member e-mail
center, along with enhancements of transparency tools
• Focused continuous process improvement (CPI) and other improvement efforts on reducing
“Customer Effort,” both exertion and interpretation of effort
• Continued improvement of NaviNet to optimize practitioner/facility use of electronic services to
include but not be limited to: benefits, claim status, service and medical review/authorization
• Implemented provider call analysis to better understand provider contacts into the call center
We will continue initiatives to
improve member awareness of
preventive health care.
2015 Goals
• Continue initiatives to improve member awareness of, access to and utilization of preventive
health care and recommended screening services through key clinical initiatives, including:
–– Comprehensive diabetes care and diabetic retinal eye examination
–– Cardiac care and cholesterol management, beta blocker treatment and hypertension control
–– Appropriate use of antibiotics in the treatment of pharyngitis and upper
respiratory infection
–– Implementation of Women’s Health initiative targeting members for age-specific
screenings and immunizations
–– Preventive health care, including:
·· Breast cancer, cervical cancer, colorectal cancer and chlamydia screening
·· Prenatal/postpartum care
·· HPV vaccines for adolescents
·· Pediatric immunizations
–– Behavioral health care with follow-up after hospitalization and follow-up for children
prescribed attention deficit hyperactivity disorder medication
–– Lead screening in children
–– Hospital safety
–– Appropriate emergency room use
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• Increase member and provider satisfaction with key service and provider initiatives:
–– Continued process improvement to address first-contact resolution, next-issue
avoidance and call escalation
–– Continue development of empowerment guidelines and service consultation model to
allow issue resolution with the first call
–– Continued revision and enhancement of the Blue Cross of Northeastern Pennsylvania
Internet site, including increasing services available on the member portal at bcnepa.com
–– Expand the IVR service with benefit accumulators and claims enhancements
–– Provide increased access for customers to receive real-time information that will assist
them in managing their health care
• Increase the coordination of care between primary care physicians, specialists and facilities
to improve the efficiency and effectiveness of members’ care and services
• Support expansion of Patient Centered Medical Home with designated providers to improve
health outcomes and reduce health care costs by enhancing communication, medication
safety and coordination of care and services
• Promote transparency reporting at an individual physician level to assist members in
selecting high quality, low cost practitioners and providers
• Enhance processes to ensure the ability of the Health Plan to provide information to members
with cultural, language or health literacy concerns, to promote an understanding of their benefits
and the services available to them as Blue Cross of Northeastern Pennsylvania members
If you would like more information about
the QI Program, our work plan or our
progress in meeting our goals, please call
Diane Jones, manager Quality Management/
Clinical Appeals, at 570.200.4396,
weekdays, between 8 a.m. and 5 p.m.
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