Kaiser Permanente service delivery standards
OUR MODEL OF CARE
Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Option, Inc. (Kaiser Permanente) is a not for profit insurance company and part of the national Kaiser Permanente family of health plans. Washington Permanente Medical Group (WPMG) is an independent medical group contracted with Kaiser Permanente to provide care for its members. In combination, Kaiser Permanente is first and foremost a clinical care delivery system that consists of Kaiser Permanente facilities and clinicians and an external, contracted provider network that extends patient care to regions or specialties not serviced by WPMG physicians. The Kaiser Permanente model of care centers on primary care, prevention, evidence-based medicine, integration and communication between specialties, effective resource stewardship and providing the highest quality of care possible.
Our relationship with our network providers
Because our contracted network forms an important part of the clinical care delivery system, it is imperative that we develop relationships that align with the Kaiser Permanente clinical care model. Kaiser Permanente views physician leadership and clinical connections as the best way to achieve its goal of high quality, affordable healthcare. To this end, WPMG takes an active role in leading physician professional relationships and supports our provider services teams when clinical issues or concerns arise. WPMG’s goal is to develop excellent partnerships through physician-to-physician conversations that center on patient care, guided by Kaiser Permanente’s clinical model. This provider manual lays the foundation for alignment and integration between Kaiser Permanente and its contracted network providers.
Expectations
We work with professional groups contracting with Kaiser Permanente to help them understand that, unlike with traditional health plans, they are participating in an integrated delivery system with a specific model of clinical care. Successful partnership involves aligning with this model of care and participating in its processes.
The following sections represent the key components of our network model of care for effective partnering in patient care.
Commitment to Quality Improvement
Kaiser Permanente and the Provider commit to:
- practice evidence-based medicine as outlined in the Clinical Guidelines posted on the Kaiser Permanente provider website
- engage in quality improvement initiatives
- cooperate regarding quality improvement initiatives, including the use of Kaiser Permanente quality reporting data, working together to improve quality metrics data and reporting tools
- collaborate with Kaiser Permanente’s Patient Safety department through Unusual Occurrence reporting as referenced in the provider manual and report safety concerns through our confidential hotline: (1-866-442-7828)
Referral Management/Care Coordination
Referral for specialty/subspecialty care, including imaging and laboratory services should, whenever possible and appropriate, be directed toward Kaiser Permanente medical centers or network specialists as reflected in the Provider Directory. Contracted providers are highly encouraged to use Kaiser Permanente facilities for imaging and lab when appropriate. Please refer to our referral guidelines for more details regarding referrals for specialty/subspecialty care.
The Referral Management Unit (RMU) is a resource to help referring providers learn the best referral options for Kaiser Permanente members prior to requesting a referral authorization. The RMU will:
- Bring referred services back into Kaiser Permanente, where possible and appropriate, to better coordinate care, improve health outcomes, and reduce patients’ out-of-pocket costs
- Ensure that the clinical intent of the referring clinician is accurately reflected in the services requested
- Reduce the number of denied referrals, and by extension, frustrated members
- Establish standard work and improved referral data quality within the referral system
- Operate as a central source of referral knowledge to support clinical teams in navigating the referral system
Assistance with prior authorization requests can be facilitated by Kaiser Permanente Review Services at 1-800-289-1363 or Kaiser Permanente Provider Assistance Unit at 1-888-767-4670.
Emergency Patient Resources and Options (EPRO) Hospitals and emergency departments can contact the EPRO line (1-800-337-3197) prior to transferring or admitting patients for care at other facilities. This will assure that the patient will receive the best coordination of care and benefits during and after transfer to another facility.
Pharmacy
Kaiser Permanente provides its drug formulary for reference when prescribing medication for Kaiser Permanente members. For assistance with our Pharmacy drug formulary exceptions, please refer to the Pharmacy Help Desk page on our provider website.
Drug Sampling Discouraged
Drug sampling to patients leads to excessive pharmacy costs and often does not provide the best quality of care to patients long-term. Within Kaiser Permanente facilities, the following policy is in effect:
Washington Permanente Medical Group staff shall not distribute samples of any drug or nutritional product, including prescription products, medical foods, pharmaceutical devices, over-the-counter products, natural products, or dietary supplements, in any Kaiser Permanente clinic or facility.
Kaiser Permanente recommends that contracted providers adopt similar policies to discourage drug sampling.
Care Management Programs
Kaiser Permanente Care Management offers effective programs to contracted providers and members that will improve quality outcomes, access to services and financial performance. These Care Management Programs improve quality outcomes and access to services for members, as well as improve financial performance for contracted providers.
Patient Experience
Kaiser Permanente and its contracted providers work together to provide Kaiser Permanente members an excellent customer service experience. Providers are encouraged to use industry-standard patient surveys and feedback received by the Kaiser Permanente Member Services contact center, Kaiser Permanente staff, and Patient Safety Unusual Occurrences reviews as opportunities for continuous improvement of member experience.
Additional Contacts/Information:
Emergency Patient Resources and Options (EPRO): 1-800-337-3197 or visit Emergency patient management
Requests for medical record information
We request that all contracted and employed providers, and administrative staff in the Kaiser Permanente enterprise comply in a timely manner with requests from Kaiser Permanente for medical record documentation. Your prompt action facilitates timely access to care and service for patients. Provider organizations can collaborate with Provider Services for access to the provider organization’s Electronic Medical Records (EMR).
Secure Email Transmission
Contracted provider groups and Provider Services will work together to establish a secure email transmission portal to expedite communications requiring Protected Health Information (PHI).
Use of Third Party Apps for Billing Services
Contracted providers who utilize third party payment apps (e.g., Venmo, Paypal, etc.) as a billing service must: (i) comply with applicable financial privacy laws, (ii) utilize a business account within the app, and (iii) configure the account settings to not allow public access to identifying information about the patient or payor, or services provided.
Professional Conduct
All contracted and employed providers, and administrative staff in the Kaiser Permanente enterprise must conduct themselves professionally in their interactions with patients, providers, support staff and administrative staff. Kaiser Permanente follows and enforces the State of Washington Medical Quality Assurance Commission policy regarding "Practitioners Exhibiting Disruptive Behavior" in its contractual relationships and in its credentialing reviews.
Documentation and Coding
Kaiser Permanente and contracted providers are encouraged to participate in efforts to improve documentation and coding accuracy, including the use of feedback and education provided by Kaiser Permanente to improve accuracy in documentation and coding, improve coding data, and improve reporting tools.
Race, Ethnicity and Language Equity
As a matter of policy and as a part of our values, we strive to match our contracted provider network to the cultural needs and preferences of our Kaiser Permanente membership. We attempt to keep records and perform analyses of our contracted provider network pool by race, ethnicity and language so we have the information at hand when a member makes a request based on cultural need and/or preference. Contracted provider groups are encouraged to support Kaiser Permanente in our efforts to better meet member needs by allowing and supporting us in our efforts to gather data on practitioners’ race, ethnicity and language(s) and to compare our provider network to the communities we serve.
Provider Directory
CMS, federal and state regulations require that we maintain a compliant and accurate provider directory of our networks. In order to meet these regulations and provide the best care options for our members, our contracted providers are expected to provide us with all demographic changes and updates as soon as possible. For more information and to make changes, please see our Provider update forms page.
SELF-TREATMENT OR TREATMENT OF IMMEDIATE FAMILY MEMBERSs
Kaiser Permanente concurs with the recommendation of the American Medical Association (AMA) and the Washington State Medical Association that in order to avoid the potential for ethical conflicts, providers should not treat themselves or their immediate family members.
Kaiser Permanente prohibits a provider from prescribing controlled substances for his or her own use and from prescribing controlled substances to a member of his or her immediate family, except in an emergency situation or isolated settings where there is no qualified physician available within a reasonable proximity. In addition, Kaiser Permanente medical offices will not accept orders or prescriptions from providers ordering services for themselves or an immediate family member.
The purpose of this policy is to avoid potential risks related to conflict of interest, lost objectivity, and invasion of privacy. Professional objectivity may be compromised and/or a conflict of interest may exist when the provider, or an immediate family member, is the patient. The provider's personal feelings may unduly influence his or her professional medical judgment, thereby interfering with the care being delivered. Immediate family members may be reluctant to state their preference for another provider or decline a recommendation for fear of offending the provider. In particular, minor children may not feel comfortable refusing care from their parents. Likewise, providers may feel obligated to provide care to immediate family members even if they feel uncomfortable.
There are also privacy concerns that must be considered. Advances in technology have resulted in patient health records that are more complete and may contain more information than paper charts. Provider treatment of self or immediate family members may result in access to information that would be a violation of patient privacy and/or Kaiser Permanente policy.
Kaiser Permanente recognizes that there are occasions where it may be appropriate to treat immediate family members that should be limited to:
- Emergency situations or if there is no other proper medical care available at the time of care.
- Immediate care for minor conditions until the patient finds a qualified physician.
All recognized follow-up care should be communicated and arranged with the provider who has responsibility for the ongoing care of the member, or the consulting provider involved in the member's immediate care episode.
Definitions
For the purpose of this policy the following terms are defined as:
Immediate family members:
- Spouse or partner
- Natural or adoptive parent, child, or sibling
- Stepparent, stepchild, stepbrother, or stepsister
- Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law
- Grandparent or grandchild
- Spouse of grandparent or grandchild
- Any other individual to whom the provider has personal or emotional involvement that may render the provider unable to exercise objective professional judgment in reaching diagnostic or therapeutic decisions.
Provider includes:
- Pharmacists
- Physicians
- Physician assistants
- Nurse practitioners
- Nurse midwives
- Registered nurses
- Licensed practical nurses
- Nurse anesthetists
- Psychologists
- Social workers
- Medical assistants
- Physical therapists
- Occupational therapists
- Speech therapists
Treating encompasses the performance of any controlled act including:
- Ordering and performing tests
- Making and communicating a diagnosis
- Prescribing medications
It does not include the monitoring of a condition that may be conducted by unlicensed individuals.
Emergency situation:
- Exists when an individual is experiencing severe suffering, or is at risk of sustaining serious bodily harm if medical intervention is not promptly provided and no other proper medical care is available.
Minor condition:
- Generally a non-urgent, non-serious condition that requires only short-term, routine care, and is not likely to be an indication of, or lead to, a more serious condition.
COMMUNICATING WITH OUR MEMBERS
As a Medicare Advantage Organization (MAO), Kaiser Foundation Health Plan of Washington is required to adhere to numerous state and federal guidelines regarding marketing and communication with our enrollees (42 CFR 422.2268, 423.2268, 422.2262, and 423.2262).
In the event of any co-branding activity by Kaiser Permanente and any provider, such provider agrees to comply with the Medicare Communications and Marketing Guidelines with respect to all marketing materials related to such co-branding activity with Kaiser Permanente.
Kaiser Permanente is ultimately accountable for all provider communications to its enrollees. To ensure compliance with state and federal requirements, all proposed provider communications must be submitted to Kaiser Permanente for review and approval prior to mailing. Additionally, Kaiser Permanente may need to submit the materials to regulatory bodies to obtain approval prior to use.
In order for Kaiser Permanente to have adequate time to review and respond to your request, please submit draft provider communications at least 60 days* in advance to:
Kaiser Foundation Health Plan of Washington
Provider Relations Compliance
PO BOX 34262
Seattle, WA 98124-1262
prcompliance@kp.org
Provider Relations Compliance will notify you in writing once your request has been received and once a final determination has been made.
*In some instances, it can take Centers for Medicare and Medicaid Services (CMS) up to 45 days to review and render a decision.
Content on this page is from the provider manual | Disclaimer