Quality Improvement

The MCC 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 member's 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 MCC 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 MCC members.

If you would like more information about our QI Program, initiatives, and/or the progress toward meeting our quality goals, please contact Customer Care.

*Printed copies of information posted on our website are available upon request.

  • Standards for Medical Record Documentation

    Providing quality care to our members is important, therefore, MCC 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.

    MCC’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

    MCC maintains access to care standards and processes for ongoing monitoring of access to health care (including behavioral health care) provided by contracted primary PCPs (adult and pediatric) and participating specialist (to include OB/Gyn, behavioral health providers, and high volume and high impact specialists). 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 90% or greater availability for Emergency Services and 90% or greater for all other services. The PCP or his/her designee must be available 24 hours a day, 7 days a week to members.

    Appointment Access

    All Providers who oversee the member’s health care are responsible for providing the following appointments to MCC members in the timeframes noted:

    Medical Appointment Types                                                      Standard

    Routine                                                                                         Within 30 calendar days

    Urgent Care                                                                                  Within 24 hours

    Obstetrical Care                                                                            Within 7 calendar days in the first trimester, within 7 calendar days in the second                                                                                                                    trimester and within 3 days thereafter

    Additional information on appointment access standards is available from your local MCC Quality Department toll free at:

    CCC Plus: (800) 424-4524 (TTY 711)
    Medallion 4.0: (800) 424-4518 (TTY 711)

  • HEDIS Measures of Focus

    Our goal at MCC is to work with our providers to ensure that every member receives the very best care. In addition, state and federal governments are demanding a health care industry that is driven by quality.

    MCC monitors the following measures:

    Diabetes monitoring for members with diabetes
    Behavioral Health & Medical readmission rates
    Adolescent Well-Care Visits
    Adult access to preventive/ambulatory health services
    Prenatal and Postpartum Care
    Childhood Immunization Status
    COPD or Asthma Admission Rate
    Heart Failure Admission Rate

    MCC supports and promotes the use of evidence-based performance measures that help drive the adoption of recommended care and improvements in population health. The Healthcare Effectiveness Data and Information Set (HEDIS®), is owned by the National Committee for Quality Assurance (NCQA) and is the most widely used measure set for driving quality rating systems, as well as for its individual measures which are increasingly used by employers, health plans, and government agencies to drive pay-for-performance quality programs.

    HEDIS measures cover a wide span of indicators related to the management of physical and behavioral health. Final performance is calculated over the first six months of every calendar year for the prior calendar year. Some measures allow medical record data, and some reviews occur across a multi-year period.

    In areas of most concern to your patients, HEDIS helps compare how managed care plans perform. MCC closely monitors the HEDIS rates to help us identify opportunities for us to improve the health of our members. Our goal is to be better than 75% of other Medicaid health plans in the nation.

    Visit the NCQA website to learn more about HEDIS. Learn more about our annual HEDIS trends.

    We depend on our providers to:

    Submit accurate and complete claims and encounter data within a timely manner of the rendered service
    Ensure that you and your office staff comply with our requests for medical records in the timeframes requested
    Notify our staff or delegated vendor immediately if the patient listed on a request for medical records is not seen by your practice
    Provide medical records for a member who was seen by a provider who has retired, died or moved, as data collection can go back as far as 10
              years
    Assist us with quality improvement activities that improve the health and wellness of our population

    MCC’s responsibility is to:

    Provide education and information as needed regarding HEDIS and other performance measures for which we request your cooperation and
              assistance
    Communicate with you by phone, fax, in writing, or through secure electronic communications to request medical record documentation to verify
              service delivery

    If you have any questions, would like additional information about HEDIS®, or have suggestions for our Quality Improvement Program, please contact Customer Care.

    CCC Plus: (800) 424-4524
    Medallion 4.0: (800) 424-4518

  • CAHPS

    Each year MCC 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. MCC’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:
    CAHPS® Annual Trends

    If you have any questions, would like additional information about CAHPS®, or have suggestions for our Quality Improvement Program, please contact Customer Care.

    CCC Plus: (800) 424-4524
    Medallion 4.0: (800) 424-4518

    CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

  • Clinical Practice Guidelines

    Clinical practice guidelines are documents which seeks to guide decisions about the diagnosis and treatment of certain health conditions. Clinical practice guidelines are based on scientific evidence, review of the medical literature, or appropriately established authority. All recommendations are based on published agreed on guidelines and do not favor any treatment based solely on cost considerations.

    The recommendations for care are suggested as guides for making clinical decisions. Clinicians and their patients must work together to develop individual treatment plans that are tailored to the specific needs and circumstances of each patient.

    MCC reviews and revises guidelines as clinical evidence is updated. Once the guidelines have been reviewed and modified as needed by a dedicated Quality Improvement Committee. MCC providers will be notified of any changes and updates by fax and/or mail.

    To request a copy of any guideline, please contact MCC Customer Care.

    2021 Clinical Practice Guidelines

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee.

    Clinical guidelines are not used by Molina to decide benefit coverage. The guidelines are an educational tool to aid clinical decision-making. They are not a standard of care. The physician should adapt the guideline when clinical judgment so indicates.

    Acute Stress and Post-Traumatic Stress Disorder (PTSD)

    MCC has adopted the guideline for Acute Stress and Post-Traumatic Stress Disorder from the Department of Veterans Affairs & Department of Defense.

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Anxiety/Panic Disorder

    MCC has adopted the guideline for Anxiety/Panic Disorder from the American Psychiatric Association.

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Asthma

    MCC has adopted the Guidelines for the Diagnosis and Management of Asthma (EPR-3) from the National Institute of Health (NIH): National Heart, Lung, and Blood Institute (NHLBI).

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Attention Deficit Hyperactivity Disorder (ADHD)

    MCC has adopted the Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit Hyperactivity Disorder in Children and Adolescents from the Journal of the American Academy of Pediatrics (AAP).

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Bipolar Disorder

    MCC has adopted the guideline for Bipolar Disorder from the American Psychiatric Association.

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Chronic Kidney Disease

    MCC has adopted the Evaluation and Management of Chronic Kidney Disease Guideline from the National Kidney Foundation, Kidney Disease Outcome Quality Initiative (NKF KDOQI).

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Chronic Obstructive Pulmonary Disease

    MCC adopted the Global Strategy for Diagnosis, Management, and Prevention of COPD from the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Depression

    MCC has adopted the Treatment of Patients with Major Depressive Disorder with the Guideline from the American Psychiatric Association (APA).

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Diabetes

    MCC has adopted the guideline for Diabetes from the American Diabetes Association (ADA).

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Heart Failure in Adults

    MCC has adopted the Guideline for the Management of Heart Failure from the American College of Cardiology (ACA).

    The Clinical Practice Guideline may be accessed here.

    You may also visit the web site below for more information.

    American College of Cardiology: here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Hypertension

    MCC has adopted the Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults from the American College of Cardiology.

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Obesity

    MCC has adopted the Guidelines for the Comprehensive Medical Care of Patients with Obesity from the American Association of Clinical Endocrinologists (AACE).

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Opioid Management

    MCC has adopted the Use of Medications in the Treatment of Addiction Involving Opioid Use Guideline from the American Society of Addiction Medicine (ASAM).

    The Clinical Practice Guideline may be accessed here.

    MCC has adopted the CDC Guideline for Prescribing Opioids for Chronic Pain.

    The Clinical Practice Guideline may be accessed here.

    The above guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Perinatal Care

    MCC has adopted the Guidelines for Perinatal Care from the American College of Obstetricians and Gynecologists.

    The Clinical Practice Guideline may be accessed here - Guidelines can be reviewed by ACOG members only using a secure password.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Pregnancy Management

    MCC has adopted the Guidelines for Routine Prenatal and Postnatal Care from Michigan Quality Improvement Consortium.

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Schizophrenia

    MCC has adopted the guideline for Schizophrenia from the American Psychiatric Association.

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee April 2021.

    Sickle Cell Disease

    MCC has adopted the Management of Sickle Cell Disease Guideline from the National Heart, Lung, and Blood Institute (NHLBI).

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Substance Abuse Treatment

    MCC has adopted the Guidelines for Detoxification and Substance Abuse Treatment from the Substance Abuse and Mental Health Services Administration (SAMHSA).

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

  • Preventive Health Guidelines

    Preventive health guidelines can be beneficial to the provider and his/her patients. Guidelines are based on scientific evidence, review of the medical literature, or appropriately established authority, as cited. All recommendations are based on published consensus guidelines and do not favor any particular treatment based solely on cost considerations.

    These guidelines are meant to recommend a standard level of care and do not preclude the delivery of additional preventive services depending on the individual needs of the patient.

    MCC reviews and revises guidelines as clinical evidence is updated. Once the guidelines have been reviewed and modified as needed by a dedicated Quality Improvement Committee. MCC providers will be notified of any changes and updates by fax and/or mail.

    To request a copy of any guideline, please contact MCC Customer Care.

    2021 Preventive Health Guidelines

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee.

    Clinical guidelines are not used by Molina to decide benefit coverage. The guidelines are an educational tool to aid clinical decision-making. They are not a standard of care. The physician should adapt the guideline when clinical judgment so indicates.

    Adult Preventive Services Recommendations

    MCC has adopted the Guidelines for Adult Preventive Services Recommendations from U.S. Preventive Services Task Force.

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Recommendations for Preventive Pediatric Health Care

    MCC has adopted the Guidelines for Preventive Pediatric Health Care from Bright Futures/American Academy of Pediatrics.

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Recommended Adult Immunization Schedule for ages 19 Years or Older, United States, 2021

    MCC has adopted the Guidelines for Adult Immunization Schedule, 19 Years and Older, 2021 from Centers for Disease Control and Prevention.

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.

    Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger, United States, 2021

    MCC has adopted the Guidelines for Recommended Child and Adolescent Immunization Schedule for ages 18 years and younger, 2021 from Centers for Disease Control and Prevention.

    The Clinical Practice Guideline may be accessed here.

    The guidelines were reviewed and adopted by the MCC National Quality Improvement Committee March 2021.