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Provider Network Performance Evaluation

Date: 01/18/19

Sunrise, Florida

Sunshine Health evaluates its provider network performance on a continual basis to align with contractual requirements, member needs and company goals.

Evaluation criteria includes:

  • Completing required trainings to ensure compliance with AHCA Contract requirements. Required trainings can be found on SunshineHealth.com under “Provider Resources.”
  • Meeting appointment standards.
    • Primary Care Providers (PCPs): Urgent care should be provided within 48 hours for services not requiring prior authorization and within 96 hours for services requiring prior authorization; routine and preventive visits within 30 days; and a post hospital discharge follow up visit within seven days.
    • Ancillary providers: Care provided within 14 days of initial request for diagnosis, or treatment of injury, illness, or other health condition.
    • Specialists: Urgent care should be provided within 48 hours for services not requiring prior authorization and within 96 hours for services requiring prior authorization; new patient visits within 60 days; and a post hospital discharge follow up visit within seven days.
    • Maternity providers: Prenatal visits within four weeks until 32 weeks pregnant; every two weeks until 36 weeks pregnant; every week until delivery after 36 weeks; and postpartum visit within 21 to 56 days after delivery.
    • Behavioral health: Non-life threatening emergency care within six hours; urgent visit within 48 hours; initial visit for routine care within 10 business days; routine follow up to routine care within 30 calendar days; post hospital discharge follow up visit within seven days; and after-hours answered by live person.
    • Non-emergency transportation vendors: 90% of trips resulting in member arriving to scheduled appointment on time; not more than 0.2% of requests resulting in a missed trip; 85% of unscheduled trips fulfilled within three hours of the request; 90% of scheduled Leg A trip requests fulfilled within 15 minutes of scheduled pick up time; and 90% of scheduled Leg B trip requests fulfilled within 30 minutes of scheduled pick up time.
  • Availability of after-hours care. Sunshine Health is committed to increasing access to care, and we encourage provider groups to have evening (after 5 p.m.) and weekend hours.  Please check our “Find a Provider” tool on SunshineHealth.com to ensure your extended office hours can be seen by members searching for providers.
  • Certification as Patient Centered Medical Home (PCMH).  Sunshine Health encourages PCPs to achieve this certification. PCMH creates an environment of efficiency by leveraging technology and best practices. Sunshine Health offers assistance to offices seeking to achieve or renew certification.
  • Engaging new members. The most important step in providing efficient and effective healthcare is by engaging members. Sunshine Health’s goal is to have each new member seen by their PCP within 90 days of assignment. By engaging new members, PCPs can start to develop a patient/provider relationship.  
  • Member loyalty. Sunshine Health believes members who are seen by their PCPs on a regular basis tend to be more loyal to their providers and receive necessary care services in appropriate settings, reducing unnecessary emergency and urgent care utilization. Members are considered loyal if they see their assigned PCP group. Sunshine Health’s goal is for PCPs to have at least 70% of their assigned members fall into this category.
  • Quality of care. PCPs are expected to close Healthcare Effectiveness Data and Information Set (HEDIS) care gaps. Sunshine Health provides tools, such as Interpreta on the Availity Portal, to identify gaps at the member or PCP level to assist in gap closure. Sunshine Health also offers a Pay for Performance (P4P) program for PCPs to encourage preventive care.  At a minimum, Sunshine Health’s expectation is that the rates for these P4P measures are at least the 50th percentile rate.
  • Cost of care. Sunshine Health uses Health Benefit Ratio (HBR) to determine PCP effectiveness in managing healthcare costs. HBR is calculated by dividing total medical expense by total premium.
  • Value-based purchasing (VBP). Sunshine Health participating PCPs are under the P4P program, which is part of the VBP continuum.  As PCP groups demonstrate excellence as evidenced by proper use of Sunshine Health tools, attaining PCMH status, achieving a high rate of P4P earnings with emphasis on quality, and successful cost management, they may qualify to move from a Fee-for-Service agreement to a Capitated/Shared Risk agreement.  Additional P4P programs are being developed for specialty types.
  • Potentially Preventable Events. Sunshine Health will begin to evaluate trends for potentially preventable events for admissions, readmissions and emergency room visits. We will share with PCPs and hospitals the rates and collaborate with our providers to develop strategies to avoid these events.
  • Birth Outcomes. Sunshine Health will begin to evaluate trends for primary C-Sections, rate of prematurity and rate of NAS babies. We will share these reports with maternity providers and hospitals and collaborate with our providers to develop strategies to improve birth outcomes.

We appreciate your partnership and look forward to achieving our shared improvement goals.