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HPSM is ranked #6

out of the state's 56 Medi-Cal plans based on Healthcare Effectiveness Data and Information Set (HEDIS) performance measures.

CareAdvantage CMC Program was ranked #3

out of all Medicaid-Medicare plans nationwide in 2016 based on a Center for Medicare & Medicaid Services (CMS) survey of enrolled members.

HPSM's Medi-Cal program earned Accreditation status

in January 2020 from the National Committee on Quality Assurance (NCQA), an independent, not-for-profit organization dedicated to improving health care quality.

Quality Assessment

How we assess quality

HPSM is committed to high quality of care. Some of the activities we do to monitor and measure quality are described below.

Healthcare Effectiveness Data and Information Set (HEDIS)

The Healthcare Effectiveness Data and Information Set (HEDIS) is a standardized set of performance measures developed by the National Committee for Quality Assurance (NCQA) to evaluate consumer health care. These measures allow HPSM to not only assess plan effectiveness internally, but to compare performance against other health plans nationally.

Below is a link to our most current HEDIS reports, which shows where HPSM scored against the national high performance level benchmarks on key measures.

Potential Quality Issues (PQI)

A PQI is a suspected deviation from provider performance, clinical care or outcome of care. HPSM uses a method to identify, report and process PQIs. If a PQI is detected, we take appropriate actions based upon outcome, risk frequency and severity. This helps us improve the care provided to our members.

For more information and resources on the handling of PQIs, please visit our PQI Page.

You can also call 650-616-2170 or email pqireferralrequest@hpsm.org.

Facilities Site Review (FSR)

HPSM conducts facility site reviews for new primary care providers (PCP) as a requirement for participation in all of our programs. New PCP sites must pass their initial FSR before receiving HPSM member assignments. Corrective Action Plans are required for those providers who do not meet the minimum required score.

Facility site reviews are conducted by DHCS-Certified Nurse Reviewers and include a site review survey, medical record review and physical accessibility review survey assessment.

The purpose of the reviews is to help ensure consistent compliance with DHCS clinical and administrative standards. A detailed explanation of these standards can be found on the DHCS website.

Tools Used

The following documents are designed to help HPSM providers prepare to successfully pass an upcoming site review. For assistance and more information contact 650-616-2165.

Required Score

  • A pre-contractual provider must score above 80% on the site review survey to be counted as a network provider.
  • Providers who score below 80% will be re-surveyed and must pass the site review survey at 80% or higher.
  • Providers that score 80—89% will be required to complete a Corrective Action Plan within specified timelines.

Monitoring

The California Department of Health Care Services (DHCS) requires all Medi-Cal Managed Care Plans to conduct a Full Scope Facility Site Review (FSR) and Medical Record Review (MRR).

After the initial site review, the maximum time period before the next required site review is 36 months. Interim monitoring will occur within this time period to assess compliance to the critical elements of the site review or to follow up with findings from previous reviews. Health Plan of San Mateo may review sites more frequently, or when determined necessary based on prior findings.

NCQA - National Committee on Quality Assurance

HEDIS and Quality Measurement

This provides information on how measures identified by NCQA apply to HPSM's Medi-Cal, CareAdvantage Cal Mediconnect program (Medicaid-Medicare Program).

Medi-Cal Managed Care and Quality Improvement

This provides information on the State’s evaluation activities and reports on required measures in quality, access, and timeliness.