Compliance Program/Fraud and Abuse Prevention
Ped-I-Care has an active Compliance Program that is constantly monitoring and auditing for potential fraud and/or abuse by providers, members, and staff. All Ped-I-Care employees have successfully completed Compliance Training. Staff members are sent weekly emails regarding fraud and abuse cases throughout Florida and the country, along with applicable guidelines by which to learn from the reports and prevent problems from occurring within the organization. Ped-I-Care has developed an online Compliance Training tutorial to educate providers about fraud and abuse, and these efforts are powered by the leadership of a team of in-house Certified Professional Coders and Certified Professional Medical Auditors. Click here to view the 2016 Ped-I-Care Compliance and Anti-Fraud Plan.
HEDIS Performance Measures
Ped-I-Care received the top score in five HEDIS performance measures (Adolescent Well Care; Adult Access to Preventive Care, ages 20-44 and Total; Immunizations for Adolescents; Asthma; and Follow-up after Hospitalization for Mental Illness, 7-day and 30-day). Ped-I-Care leadership continues to focus on improvement and is making progress in all performance measures.
For 2009, Ped-I-Care Title 21 members had a compliance rate of 98% for child health check-ups and for immunizations at age 2 years. Efforts to continue improving compliance performance include sending providers a list of children assigned to them who are in need of services, immunizations, or child health check-ups. Additionally, attempts are made to contact Title 19 members through the mail and by phone with reminders to schedule services.
Performance Improvement Projects
Each of Ped-I-Care’s four Performance Improvement Projects, or PIPs, has been approved by AHCA and the program is seeing results from its planned interventions. Through the measurement process, the program has discovered novel ways to reach out to members. The key to PIP success is the collaborative manner in which Ped-I-Care works with other carriers/programs in the state of Florida, along with state institutions and experts to improve access to and quality of care. Immunization rates for children under the age of two have been improving. In fact, in both its immunizations and behavioral health PIPs, Ped-I-Care set and surpassed aggressive benchmarks. With behavioral health, after having met the outlined goals, the program has continued to create high annual targets for service improvement.