Quality Improvement Program

A priority at Medical Mutual is to build a family of companies that meets the needs of our members, policyholders, customers and communities. To support this, Medical Mutual's Care Management department has implemented a comprehensive Quality Improvement (QI) program and continually redesigns this program to:

Manage benefits that improve the health and wellbeing of our members and optimize performance by implementing the Institute for Healthcare Improvement’s Triple Aim approach: improving population health, improving member experience for care, and reducing per capita cost.
Provide consistent standards, measurements, and reporting to support local and regional quality improvement strategies.

Quality Improvement Program Activities

To learn more about specific QI program activities developed by Medical Mutual, please select a topic from the list below.

Member and Provider

Accessibility Standards

Medical Mutual’s goal is to ensure that each member has timely access to provider treatment. Standards have been established for network primary care providers (PCPs), specialists and behavioral health professionals.

These standards are published annually in provider newsletters, provider directories and posted on this website. It is also available for members on their benefits portal. Compliance with accessibility standards is monitored via audits and Healthcare Effectiveness Data and Information Set (HEDIS) member satisfaction surveys. In addition, QI staff review member complaints regarding access and implement provider corrective action plans (CAPs) as indicated.

Care Management Department

Utilization management (UM), case management and chronic condition management activities comprise a comprehensive care management program and are integrated with clinical quality improvement activities. All care management and quality improvement activities report through the same committee structure, and all staff ultimately report to the Chief Medical Officer for clinical issues and the Vice President, Clinical Quality & Health Services for all administrative issues.

UM activities within care management include prior approval, concurrent review, retrospective review, discharge planning, chart audit and medical claims review for medical/surgical and mental health/substance abuse services.

Case management is a multidisciplinary process and involves the coordination of complex care needs while facilitating flexible, individualized plans of care and utilizing community resources. This process is a collaborative effort between the member, family, physician and other members of the healthcare delivery team. The case management process provides cost-effective options for selected members with complex medical and social needs.

Population Health Management

The Medical Mutual Chronic Condition Management Program (CCMP) provides both digital and telephonic options that are customized to support members as they work to improve their health. Our CCMP is available for members diagnosed with one or more chronic health condition(s). Programs connect eligible members with a specially trained clinical staff (RN) or personalized digital coach who provide individualized support and education that reinforces evidence-based treatment and self-management of conditions. Programs are available to members diagnosed with the following conditions:

Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Heart Failure (CHF/HF)
Coronary Artery Disease (CAD)
Diabetes Prevention
Diabetes Management
Hypertension (HTN)

We also offer our members a Maternity Management program, which promotes timely, regular prenatal care and offers support and education to expectant mothers by a digital smartphone app customized for Medical Mutual members. The program seeks to identify high-risk pregnancies and provide education aimed at avoiding or minimizing possible complications through careful clinical management in cooperation with the treating physician.

Expectant mothers who engage with the Med-Mutual Maternity app learn about the importance of early and regular prenatal care and self-care strategies that support their overall health and the health of their unborn children. In addition, members have access to perinatal nurses who are available to offer support and answer questions the expectant or new mother may have all the way through the child’s second year of life.

Pregnant members who at the highest risk level are connected with home services such as progesterone injections to help them progress towards a full-term delivery.

Contact the Care Management Department.

Clinical Care and Service Studies

Each year, Medical Mutual identifies clinical and service concerns/topics for focused studies and interventions. Selection of topics is made with substantial input from the Clinical Quality and Resource Management committee. A variety of sources are utilized to identify topics, including HEDIS, care cost analysis, member demographics analysis, claims data analysis, medical record reviews, provider and member surveys and referrals of potential quality issues. The objective in identifying topics is to ensure they represent and address the needs of the member population. Topics may address the total population or specific segments of members (e.g., women of childbearing years, members with asthma) and are centralized around current clinical programs.

Educational Communications

Medical Mutual continues to channel its efforts toward the educational component of quality improvement. Providers receive information via the Provider Manual, quarterly newsletters and during collaboration meetings. Members receive newsletters, direct mailings, messages on the member portal and their certificate of coverage.

The physician newsletter and the member newsletter, Healthy Outlooks, contain articles highlighting critical care and health information, in addition to articles that focus on member safety in various settings. Healthy Outlooks articles encourage members to take an active role in helping to prevent injuries and errors that might affect their safety.

Medical Mutual's Clinical QI department may be contacted at 1-800-586-4523

Preventive Care Service

Clinical preventive care service is an essential aspect of medical practice today. To promote the delivery of regular preventive care services by physicians and utilization of such services by members, Medical Mutual annually reviews preventive care guidelines. The guidelines are developed and updated by the Clinical QI Department and participating network physicians biennially, or when appropriate. The guidelines are considered minimum standards which all PCPs are expected to meet when providing routine medical care to members.

Members

Appropriate Care

To ensure all members receive the most appropriate medical care available, Medical Mutual has a team of people who review certain treatments, tests or hospital through the “utilization management” process. Medical Mutual distributes an appropriate care statement to all employees, contracted physicians and management staff who deal with utilization management activities stating the following:

Utilization management decisions are based only on the appropriate use of care and services for the member and existence of coverage.
Medical Mutual does not directly or indirectly reward or incentivize providers or any other individuals participating in utilization management decisions for denying or limiting coverage or service.
Medical Mutual does not provide financial incentives for utilization management decisions that result in the underutilization of care or service.
Decisions regarding hiring, compensation, termination, promotion or other related matters with respect to any individual are not made based on the probability that the individual will support a denial of coverage.
In addition, they: (1) do not participate in underwriting activities; (2) are not involved in determining or advancing corporate profitability; and (3) their activities are not monitored or directly controlled by anyone with such authority or responsibility.

Company-wide Member Appeals Monitoring

Medical Mutual has a formal process for members that advises them of their right to file an appeal and provides timeframes for appeal resolution. Members are informed of their rights through their certificate of coverage, medical determination letters, Explanation of Benefits statement (EOB), and member newsletters. Members are also notified of their rights when they contact the Customer Care department with a grievance about a denied claim or service. Grievances are tracked for timeliness and trended to identify potential issues for quality improvement intervention.

Safety Monitoring and Activities

Medical Mutual’s patient safety plan provides the framework for an integrated and comprehensive program to monitor, assess and improve the quality and safety of patient care delivered to our members.

This plan supports the organizational mission to provide clinical excellence at a reasonable cost and to continuously improve patient outcomes.

Medical Mutual’s approach to improving clinical and service quality includes three key processes: measurement, analysis and improvement.
Patient care and service processes, as well as outcomes are measured using quality indicators and data collection techniques.
Analysis of collected data is used to determine levels of performance and to quantify variation in processes and outcomes.
When there is an identified opportunity for improvement, the decision to act will depend upon a prioritization process that considers factors referenced in the guiding principles outlined in the patient safety plan.
When an opportunity for improvement is prioritized for action, the Plan-Do-Check-Act (PDCA) or other proven methodologies are employed to drive change.

The quality and patient safety infrastructure supports Medical Mutual’s commitment to safety, quality, evidence-based medicine, and continuous learning to provide the highest level of care to the communities we serve.

Satisfaction Measurement and Improvement

Maintaining high levels of member satisfaction is a primary goal of the QI program. Objectives of member satisfaction activities are to:

Provide members with opportunities to express their opinions about Medical Mutual products and service.
Share member perceptions with providers to encourage performance improvements.
Utilize member input to identify potential areas for quality improvement action.
Vehicles utilized to achieve the above objectives include:
- Member satisfaction surveys, including general surveys and surveys focused on specific products, populations or concerns
- Analysis of member complaints and appeals
- Monitoring telephone service and implementing corrective action plans to achieve optimum results regarding the following service parameters:
  - Incoming calls per day
    - Wait time to reach a service representative
    - Calls connected (caller remains on the line)
    - Time required to access customer's claims history
    - Number of inquiries resolved on initial contact
    - Turnaround time for inquiries unresolved on initial contact

Medical Mutual tracks member complaints for timeliness and trends the complaints to identify potential issues for quality improvement intervention.

Provider

Affirmative Statement

Medical Mutual is committed to ensuring the appropriate utilization of care and service provided to all members. To ensure this commitment, Medical Mutual has asked all employees, consultants, and management staff involved in utilization management decisions to sign a statement that affirms their understanding of the following:

Utilization management decisions are based only on the appropriate use of care and services for the member.
Medical Mutual does not directly or indirectly reward or incentivize providers or any other individuals participating in utilization management decisions for denying or limiting coverage or service.
Medical Mutual does not provide financial incentives for utilization management decisions that result in the underutilization of care or service.

Practice Guidelines

To promote the provision of quality healthcare services and the management of selected conditions and chronic diseases, Medical Mutual develops and disseminates practice guidelines to providers for input and adoption. Guidelines include: Alcohol/Substance Use Disorder, Depression, Diabetes, Hypertension and State of Ohio Opioid prescribing rule and guidelines. Practice guidelines are reviewed at least every two years and updated as necessary to reflect changes in medical practice.

Medical Mutual monitors physician compliance with published guidelines via periodic medical record review, claims data analysis and Compliance, Quality and Risk Management (CQRM) committee input. Results of monitoring activity are analyzed and used to develop and implement interventions for the education of providers regarding the Medical Mutual guidelines.

Network Availability Measurement and Improvement

To ensure that network providers and hospitals are available to members, Medical Mutual has established standards for the following:

Appropriate ratios of PCPs and specialists to members
Geographic location and travel time to providers/hospitals

Medical Mutual seeks to maintain a comprehensive practitioner network available for its members. Medical Mutual defines specific goals in comparison to the total available practitioner population and geographic availability across practitioner specialties. In addition, Medical Mutual monitors member complaints and member satisfaction regarding provider network availability across practitioner specialties as well as cultural and/or linguistic needs. With these goals, members will have sufficient practitioner alternatives available to meet their medical needs. Once goals are attained in a region, recruiting efforts are terminated and resources are focused on improving practitioner availability in deficient areas.

Network Clinical and Service Issues

The QI program is responsible for identifying potential clinical and service issues, investigating potential causes and solutions, taking action to improve performance and evaluating the effectiveness of these actions.

Personnel from the following operational areas are primary sources for identifying possible concerns regarding quality of care and service:

Benefit Administration
Care Management
Claims/Member Services
Clinical Credentialing
Clinical Quality Improvement
Marketing
Network Management
Professional Contracting

Cases with potential clinical or service issues are tracked and monitored regularly. Clinical issues are referred to the Quality department for review and may result in review by the Chief Medical Officer.

In cases where provider performance issues are noted and improvements are not achieved within reasonable time-frames, Medical Mutual has instituted a provider termination process. The policies and procedures on termination include a formal provider appeal process where appropriate.

Satisfaction Measurement and Improvement

Maintaining high levels of provider satisfaction is another goal of the QI program. Objectives of provider satisfaction activities are to:

Afford providers the opportunity to express their opinions about Medical Mutual policies and procedures regarding claims payment, the Care Management process, and various administrative components of the managed care products
Share provider perceptions with internal Medical Mutual departments to encourage performance improvements
Utilize provider input to identify potential areas for quality improvement action

Vehicles utilized to achieve the above objectives include:

Provider satisfaction surveys.
Analysis of provider comments in response to the distribution of guidelines, newsletters, and other communications

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