Enhancing Provider Networks: Coventry's Quality Improvement Program
Jean Costello
Director, Quality Improvement
Coventry's Network Quality Improvement Program is comprehensive, systematic, on-going, and compliant with provider network regulations. The program's goal is to optimize the quality of the provider network available to injured individuals while maintaining cost-effective utilization of resources.
The key objective of program is to continuously review and evaluate the accessibility, availability, appropriateness, continuity, and coordination of care through:
- Provider and injured individual satisfaction survey results
- Medical record audits
- Complaints and grievance investigations
- Utilization management data and claims data
A Quality Analyst reviews all complaints against a provider, and if required, medical director to determine if the provider should be monitored or in the case of significant severity, the case is sent to the credentialing committee for potential provider improvement plan or removal action. If the committee decides to remove the provider from the network, notification of removal is sent to the provider informing them of their right to appeal within 30 days. Appeals are reviewed by the Quality Improvement Committee with the outcome of the appeal sent to the provider in writing.
The Coventry Network Quality Improvement Program is designed to ensure that our network exceeds the expectations of the injured individuals who access it and the adjusters and nurses who use it in the care management of the individuals they serve.