Provider Quality Resources

Quality Resources

The Centers for Medicare & Medicaid Services (CMS) uses a five-star quality-rating system to measure Medicare beneficiaries’ experiences with health plans and the health care system. This rating system applies to the Medicare Advantage (MA) line of business and is a key component in financing health care benefits for MA plan enrollees. In addition, ratings are posted on the CMS consumer website, www.medicare.gov, to help beneficiaries choose among the MA plans offered in their areas.

State and federal governments are increasingly moving toward a health care industry driven by quality. Health care professionals likely have noticed increased activity regarding quality initiatives among MA payers. Therefore, health care professionals should understand the metrics included in the CMS rating system.

Some of the metrics are part of CarePlus’ Provider Star Rewards program, in which you may be eligible to participate. Please scroll down for more information about the program.

CarePlus has developed the resources below to help physicians, clinicians and managed service organizations navigate the quality landscape.

CarePlus Quality Improvement Program Overview

CarePlus’ Quality Improvement (QI) Program encompasses clinical care, preventive care and member services. Please click 2017 CarePlus Quality Improvement Program Description Overview for information about our QI program and the progress we’ve made toward our goals. Health care providers may also obtain the report by calling the Quality Operations, Compliance and Accreditation Department at 1-305-626-5195, Monday through Friday, from 8:30 a.m. to 5 p.m. We welcome your input regarding our QI program. Please send any comments you might have to the following address: CarePlus Health Plans; Quality Operations, Compliance & Accreditation Department; 3501 SW 160th Ave., Building B, First Floor; Miramar, FL 33027

Stars Rewards Program

CarePlus’ support of value-based reimbursement is the foundation on which we developed our quality rewards program. We offer financial rewards for improvements in quality, outcomes and cost. We created a program to encourage primary care physicians and managed services organizations in their development of population health management capability and focus.

The Stars Rewards Program is a pay-for-value program and focuses on achievements for specific National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS®) and Pharmacy Quality Alliance (PQA) measures. The Stars Rewards Program provides incentives to physicians and managed services organizations who meet Star-score weighted average thresholds. Physicians and managed services organizations that achieve these weighted average thresholds receive bi-annual reward payments.*

*This program is subject to change or termination upon prior notice from CarePlus. The plan reserves the right to offset any amounts owed by your group/vendor with Star Rewards earned under this bonus program. Any remaining dollars would be paid to your group/vendor once the balance due has been satisfied.

Questions

Health care professionals who have questions about these materials may contact their assigned provider services executive and/or their quality improvement nurse (clinical advisers), and/or email the CarePlus Stars team at CPHP.STARSDEPT@careplus-hp.com.

Care Management Member Satisfaction Surveys

The CarePlus Care Management Department conducts annual member satisfaction surveys to ensure that we’re delivering the perfect care management experience to CarePlus members. We use the results to enhance programs that help these patients manage their care and improve their health. If you would like to receive a copy of these survey results, please contact the CarePlus Care Management Department at 1-866-657-5625 or CPHP_HSD_Care_Management_Referrals@humana.com. Our phone line is open Monday through Friday from 8 a.m. to 4 p.m.