Our Quality Standards

UM / QM Programs

Our objective is to ensure that utilization is appropriate, without evidence of over or under utilization, and that our activities measurably impact favorable health outcomes for the populations that we serve:

  • Network Medical Director for each specialty
  • Specialty Advisory Committee
  • Satisfaction Surveys (PCP, Specialist, Member)
  • Clinical Outcome Studies
  • Chart Reviews
  • Toll-free numbers for members and physicians
  • Concurrent review of medical records, surgical outcome studies, and encounter reporting
  • Ongoing analyses of access & availability

Specialty Advisory Committee

The HN1 Specialty Advisory Committee ensures that specialty care meets the highest standards according to the community and the American Academy for each specialty. This includes:

  • Overview of the UM/QM program and studies
  • Provider issues pertaining to UM and QM
  • General physicians and sub-specialists in each medical specialty
  • All committee activities are overseen by a Medical Director of that medical specialty
  • Peer Review activities

Medical Direction

The Specialty Network Medical Directors of each network report to HN1's Chief Medical Officer. The role and responsibilities of the Network Medical Directors include:

  • Measuring and maintaining quality
  • Managing the interface between cognitive and procedural functions
  • Chairing the network's Credentials Committee
  • Chairing the network's Specialty Advisory Committee
  • Working closely with CMO to maintain integration of services

Quality Initiatives

HN1 has implemented numerous initiatives that focus on maintaining high physician involvement, satisfaction and quality. Some of the unique features that HN1 provides to its contracted providers and payers include:

  • Geo-capitation reimbursement model to its physicians. Under HN1's model, providers act as the gatekeeper for specialty services, thus significantly reducing Part A expenses that would otherwise be incurred by the payer under a FFS structure. In addition, geo-capitation creates high satisfaction for both physicians and members due to the reduction in referrals/claims processing and increased continuity of care.
  • Extensive UM/QM programs including:
    • In-house quality management committee headed by an HN1 Medical Director of that medical specialty
    • HN1 physician steering committee for each medical specialty
    • Provider credentialing
    • PCP, specialist, and member satisfaction tracking
    • Development of practice guidelines in accordance with curren accreditation standards
  • Toll-free numbers for member and physician inquiries
  • 24-hour access to participating providers with highly trained personnel to triage emergency referrals
  • Provider Credentialing on behalf of its contracted payers
  • Concurrent review of medical records, surgical outcome analysis, and encounter reporting
  • Ongoing analysis of office wait times, appointment scheduling, and emergency coverage

Specialty Panels

The majority of HN1's contracted providers are located in the state of Florida, primarily in the South Florida and Central Florida service areas. The medical specialties in which HN1 and/or its affiliates currently maintain at least one active network agreement with a major health plan include:

  • Dermatology
  • Ophthalmology
  • Urology
  • Gastroenterology
  • Podiatry
  • Therapy (PT/OT/ST)

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