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:

1. 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
2. Ensure that the clinical intent of the referring clinician is accurately reflected in the services requested
3. Reduce the number of denied referrals, and by extension, frustrated members
4. Establish standard work and improved referral data quality within the referral system
5. 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:

Provider Services

Clinical Review Criteria

Consulting Nurse Services

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.