Southside Hmo Case Study

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To the Board of Directors of Southside HMO: As the Chief Executive Officer (CEO) of Southside Health Maintenance Organization (HMO), I am providing a detailed report of my strategies and recommendations to make sure that the quality and management processes of our healthcare organization are being provided to all members. There has been a complaint filed against the Southside HMO that patients that are enrolled in the Health Plan are not receiving quality healthcare delivery. Southside HMO provides healthcare services for over 495,000 members located in the eastern region of the United States. These strategies and recommendations are for resolving any complaints of denial of healthcare services for referrals to see a specialist by primary…show more content…
This will include a panel review of the referrals made by the primary care providers for specialist medical treatment to produce a gap analysis of the complaint. This will be followed by an analytical report with data from the hospital integrated healthcare system to develop new processes that can ensure that workflows and procedures do not fail the referrals for specialist made by primary care and other healthcare providers. This system should also be assessed to determine if any updates or upgrades could improve the referral system. This will require some investments to the data management system to report and analyze all referral utilization information. To ensure the review processes for appeals of a denial of benefits coverage is in compliance of the law in the Employee Retirement Income Security Act (ERISA) and the Affordable Care Act (ACA). There will also be a new sub-committee formed that will include the referral coordinator to manage the continuous quality improvements to these processes and I will recommend that Mrs. Brown also be included to avoid delays addressing patient issues. The Referral Committee will also review the current policies for referrals and make recommendations to improve the referral system and determine if effective communication exists between physicians and the referral…show more content…
Questions will include their satisfaction in getting the appointments; if they were notified of their appointments in an acceptable time frame; their wait time to see a specialist; and the information they received was suitable. The results of this information will shared with referral committee to determine the referral processes that will offer the best procedures for Southside HMO and the Sunnyside healthcare organization. This is an excellent opportunity to understand the needs of our customers and also for our organizations that can provide a positive impact for the entire
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