AlohaCare
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Quality

The -AlohaCare CCS Quality Improvement (QI) Program monitors and evaluates the quality, appropriateness, accessibility and availability of health care services.

Adverse Events

Providers are required to notify CCS via the . Notification must be given within 24 hours of the time you're made aware of an incident.

-Performance Outcomes

The AlohaCare CCS QI program uses the Healthcare Effectiveness Data and Information Set (HEDIS®) to measure our behavioral health outcomes performance. HEDIS® is a mandatory process that occurs annually. Some measures we monitor include, but not limited to, the following:

  • Follow-Up after Emergency Department Visit for Mental Illness
  • Follow-Up after Emergency Department Visit for Substance Use
  • Follow-Up after High-Intensity Care for Substance Use Disorder
  • Follow-Up after Hospitalization for Mental Illness
  • Pharmacotherapy for Opioid Use Disorder
  • Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are Using Antipsychotic Medications
  • Adherence to Antipsychotic Medications for Individuals with Schizophrenia
  • Initiation and Engagement of Substance Use Disorder Treatment

Member Experience

Annually, the AlohaCare CCS QI program conducts at least one member experience survey which provides a general indication of how well we are doing to meet members’ expectations.  The Adult version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is a standardized survey used to collect information on member satisfaction and experience with healthcare services, practitioners and providers, and settings.  The survey questions reflect members’ overall satisfaction on:

  • Rating of All Health Care
  • Rating of Health Polan
  • Rating of Personal Doctor
  • Rating of Specialist Seen Most Often

Other key areas include questions on:

  • Customer Service
  • Getting Care Quickly
  • Getting Needed Care
  • How Well Doctors Communicate
  • Coordination of Care

The AlohaCare CCS program may also conduct an Experience of Care and Health Outcomes (ECHO) survey, which is another standardized survey tool designed to measure member experiences with behavioral health care, including mental health and substance abuse treatment, as well as outcomes for that care.

 

FRAUD, WASTE & ABUSE

AlohaCare wants to ensure that we are all working together to protect the resources available to serve our members. Health care fraud, waste and abuse (FWA) hurts everyone including members, providers, and taxpayers. AlohaCare is committed to protecting the integrity of the healthcare system in the fight against FWA by preventing, detecting and correcting instances of FWA. Please help us by reporting questionable activities you believe could be potential FWA.

Provider Fraud, Waste & Abuse

Some examples of provider activity that is monitored for fraud, waste and abuse:

  • Prescribing drugs, equipment or services that are not medically necessary
  • Billing more than once for the same service
  • Intentionally using improper medical coding to receive a higher rate of reimbursement
  • Billing for services not provided
  • Scheduling more frequent return visits than are needed
  • Unbundling services to obtain higher reimbursement
  • Purchasing drugs from outside the U.S.
  • Prescribing high quantities of controlled substances without medical necessity

Member Fraud, Waste & Abuse

AlohaCare monitors member activity for fraud, waste and abuse. Some examples are:

  • Inappropriately using services such as selling prescribed narcotics, or seeking controlled substances from multiple providers or multiple pharmacies
  • Sharing a member ID card
  • Obtaining unnecessary equipment/supplies
  • Changing prescription forms to get more than the amount of medication prescribed by their physician
  • Member receiving services or picking up prescriptions under another person's ID (identity theft)

Pharmacy Fraud, Waste & Abuse

Examples of pharmacy fraud, waste and abuse:

  • Prescription drugs not dispensed as written
  • Submitting claims for a more expensive brand name drug when a less expensive generic prescription is dispensed
  • Dispensing less than the prescribed quantity without arranging for the additional medication to be received with no additional dispensing fees
  • Splitting prescriptions into two orders to seek higher reimbursement
  • Dispensing expired, fake, diluted or illegal drugs
  • Billing for prescriptions not filled or picked up

Report Fraud, Waste & Abuse

  • Options that are anonymous:
    • Call our 24/7 hotline at 855-973-1852
    • Write to us or use our FWA Reporting Form and mail to:
      AlohaCare
      ATTN: Special Investigations Unit
      1357 Kapiolani Blvd,
      Suite G101
      Honolulu, HI 96814
  • Options that are not anonymous:
    • Email us at fraud@alohacare.org
    • Contact customer service toll-free at 1-800-434-1002
    • Fax: 808-973-7410
    • Report to your assigned AlohaCare Provider Representative
  • When reporting, please give a detailed description of the activity, including:
    • Name and contact info of person believed to be committing FWA
    • Date of suspicious activity
    • Issue of concern and any other pertinent information
    • Your contact info, if anonymity is not requested

Note: You may report anonymously, however if you do not provide your identity, we will not be able to contact you for more information, if needed.