Our mission is to maximize the quality of life, health, security, and independence for our members who are covered by Molina Healthcare. It is critical that we provide members with top quality care and service. We have established a Quality Improvement Team, structure and contributing resources to deliver on this goal. The Quality Improvement Team monitors nationally established indicators of business performance and compares them to benchmarks to identify opportunities for improvement.
By using this approach, Molina Healthcare is continuously working to improve the care and services it provides for members.
- Quality Improvement Program
The Molina Healthcare Quality Improvement (QI) Program provides the structure and key processes that enable the health plan to carry out its commitment to ongoing improvement of care and service, and improvement of members' health. The QI Program assists the organization to achieve these goals. It is an evolving program that is responsive to the changing needs of the health plan's customers and the standards established by the medical community, regulatory and accrediting bodies.
The key quality processes include but are not limited to:
- Implementation of programs and processes to improve members' outcomes and health status.
- Collaboration with our contracted provider network to identify relevant care processes, develop tools and design meaningful measurement methodologies for the provided care and service.
- Evaluation of the effectiveness of programs, interventions and process improvements and determine further actions.
- Designing effective and value-added interventions.
- Continuously monitoring performance parameters and comparing to Molina Healthcare standards, national and regional benchmarks, as well as regulatory requirements.
- Analysis of information and data to identify trends and opportunities, and the appropriateness of care and services.
- Oversight and improvement of delegated functions; Claims, UM and Credentialing.
- Ensuring a quality and adequate provider and Health Delivery Organization network through appropriate contracting, studies and Credentialing processes.
- Evaluating member satisfaction with their experience of care through the CAHPS® (Consumer Assessment of Healthcare Providers and Systems) survey.
- Conducting provider satisfaction surveys with specific questions about the UM process, such as determining the level of satisfaction with getting a service approved, obtaining a referral and case management.
The QI Program promotes and fosters accountability of employees and network and affiliated health personnel for the quality and safety of care and services provided to Molina Healthcare members.
If you would like more information about our QI Program, initiatives, and/or the progress toward meeting our quality goals, please contact Provider Services.
- Standards for Medical Record Documentation
Providing quality care to our members is important, therefore, Molina Healthcare has established standards for medical record documentation to help ensure the highest quality of care. Medical record standards enable, promote quality care through communication, coordination and continuity of care, and efficient and effective treatment.
Molina Healthcare's medical record documentation standards include:
- Medical record content
- Medical record organization
- Ease of retrieving medical records
- Confidential patient information
- Standards and performance goals for participation providers
For a detailed description of the standards and performance goals, refer to the Provider Manual.
- Access and Availability
Access to Care
Molina maintains access to care standards and processes for ongoing monitoring of access to health care provided by contracted PCPs and participating specialists. Providers surveyed include OB/GYN (high-volume specialists), Oncologist (high-impact specialists), and behavioral health Providers. Providers are required to conform to the Access to Care appointment standards listed below to ensure that health care services are provided in a timely manner. The standards are based on 80 percent availability for Emergency Services and 80 percent or greater for all other services. The PCP or their designee must be available 24 hours a day, seven days a week to Members.
All Providers who oversee the member’s health care are responsible for providing the following appointments to Molina members in the timeframes noted:
PCP Routine, asymptomatic Within 4-6 week PCP, persistent symptoms Within 48 hours
PCP Urgent Care
Within 24 hours
After Hours Care
24 hours/day; 7 day/week availability Specialty Care (Routine) Within 30 calendar days
Optometry Care Non- Urgent
Within 3 week
Within 48 hours
Lab and X-Ray Non-urgent
Within 3 weeks
Lab and X-Ray Urgent
Within 48 hours
Urgent Specialty Care
Within 24 hours
Behavioral Health Appointment
Life Threatening Emergency
Within 1 hour
Urgent Care Within 1 hour of presentation at service delivery site or within 24 hours of telephone contact request Persistent symptoms Seen or referred to appropriate Provider within 48 hours of reporting symptoms
Routine Care Visit
Within 3 weeks of request for appointment
Substance Use Disorder & Pregnancy (Pregnant and in need of SUD services)
Admitted within 48 hours of seeking treatment
Intravenous drug-use admitted not later than 14 days after request for admission, or 120 days after request if no program has capacity and interim services are made available within 48 hours
Additional information on appointment access standards is available from your local Molina Quality department.
Office Wait Time
For scheduled appointments, the wait time in offices should not exceed one hour. All PCPs are required to monitor waiting times and adhere to this standard.
All Providers must have back-up (on call) coverage after hours or during the Provider’s absence or unavailability. Molina requires Providers to maintain a 24-hour telephone service, seven days a week. This access may be through an answering service or a recorded message after office hours. The service or recorded message should instruct Members with an Emergency to hang-up and call 911 or go immediately to the nearest emergency room. Voicemail alone after-hours is not acceptable.
Please visit the Provider Manual for additional information on access and availability.
Molina Healthcare uses the Healthcare Effectiveness Data and Information Set (HEDIS®) tool every year for quality reporting. This is done by looking at the type of care and services provided. Along with more than 90% of American health plans, Molina Healthcare uses HEDIS® results to track quality performance from year to year and to identify opportunities for improvement. Molina's goal is to be better than 75% of other Medicaid health plans in the nation. During the first two quarters of each year, provider offices may be contacted to submit specific medical records for review, an integral part of the HEDIS® data collection process. HEDIS® data collection is in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
Detailed results can be found by clicking the link below:
Please log into our Availity Provider Portal for HEDIS® material, including annual trends, tip sheets, and a coding guide: https://apps.availity.com/.
If you have any questions, would like additional information about HEDIS®, or have suggestions for our Quality Improvement Program, please contact Provider Services.
* Printed copies of information posted on our website are available upon request.
HEDIS® is a Registered Trademark of the National Committee for Quality Assurance.
Each year Molina Healthcare sets goals to improve our services to members. Annually we measure member satisfaction using the Consumer Assessment of Healthcare Providers and Systems survey (CAHPS®). The survey looks at key satisfaction drivers through the continuum of care, including health plan performance and the member's experiences in the physician office. Survey instruments are sent to adult members and parents of child members. Results are collected and analyzed to track member satisfaction with health plan performance and to identify opportunities for improvement. Molina Healthcare's goal is to be better than 75 percent of other Medicaid health plans in the nation who report their results to the National Committee for Quality Assurance (NCQA).
Detailed results can be found by clicking below:
If you have any questions, would like additional information about CAHPS®, or have suggestions for our Quality Improvement Program, please contact Provider Services.
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).