Buckeye Health Plan does not reward practitioners, providers, or employees who perform utilization reviews, including those of the delegated entities for issuing denials of coverage or care. UM decision making is based only on appropriateness of care, service, and existence of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization. Utilization denials are based on lack of medical necessity or lack of covered benefit.
Buckeye Health Plan and its delegated health plan partners have utilization and claims management systems in place in order to identify, track, and monitor the care provided and to ensure appropriate healthcare is provided to the members.
Buckeye Health Plan has implemented the following measures to ensure appropriate utilization of health care:
- A process to monitor for under and overutilization of services and take the appropriate intervention when identified.
- A system in place to support the analysis of utilization statistics, identification of potential quality of care issues, implementation of intervention plans and evaluation of the effectiveness of the actions taken.
- A process to support continuity of care across the health care continuum.
2024 Quality Performance Programs
We are happy to deliver our 2023 Quality Incentive Program to our Primary Care Physicians. This program supports closing HEDIS-based care gaps for our members. Closing these care gaps can improve the overall health and wellness of our members, your patients, and we appreciate your active participation in the program.
The Quality program has been designed for each individual Line of Business (LOB). There are separate Medicaid, Marketplace and Medicare programs, which will allow the programs to be based on the LOB’s own population. Separating out the programs allows you to focus on measures that matter most for each LOB.
All Primary Care Physicians, who have at least one Buckeye member that qualifies for a measure, are eligible. Please see detailed information in the 2023 Quality Performance Measures document for each LOB.
We appreciate the care you provide our members and look forward to strengthening our partnership with you to close care gaps and further improve health outcomes for your Buckeye Health Plan patients.
If you have questions, please reach out to your Provider Relations representative or call 866-296-8731.