PROVIDER NETWORK

TRAINING AND ORIENTATION

1. Medi-Cal

Some of the IPAs managed by MSO, Inc. and VitalLinks, LLC. and MMSE, LLC. participate in the Medi-Cal Program. The link below gives you some basic information about the Medi-Cal Program.

Medi-Cal 101 – Answering Your Questions about Medi-Cal (cahealthwellness.com)

2. Fraud Waste and Abuse

MSO, Inc. and VitalLinks, LLC (“The Companies”) have developed a Fraud, Waste and Abuse (“FWA”) Compliance Policy to be a comprehensive statement of the responsibilities and obligations of all employees regarding submissions of information (on behalf of managed IPAs/Medical Groups) on which payment is made by the Centers for Medicare & Medicaid Services, or CMS (for Medicare) including Part D, the State of California Department of Managed Health Care (DMHC), the Office of Inspector General (“OIG”), and other government payors for services rendered by The Companies and any of its subsidiaries, divisions, and contractors. In addition, this policy is intended to apply to business arrangements with physicians, vendors, subcontractors, hospitals, brokers, agents, and other persons who may be subject to federal or state laws relating to FWA.

Detecting and preventing FWA is the responsibility of everyone, including employees, members, providers and sub-contractors. The Companies have written policies and procedures to address the prevention, detection, and investigation of suspicious activity. The Companies also conducts annual compliance training and regularly publishes articles related to FWA on The Companies’ Intranet site. The Companies have also established an Anti-Fraud Hotline (626) 656-2370, Extension 129 for employees, plan members, agents, and vendors to report suspected FWA anonymously. This hotline is available 24/7. An e-mail hotline for reporting is also available at: Compliance@msosocal.com. The Companies maintain employee training records for a minimum of ten years.

3. COMPLIANCE

HICE General Compliance

4. Clinical Protocols and Evidence-based Practice Guidelines

MSO, Inc. and VitalLinks, LLC. and MMSE and its managed IPAs and medical groups utilize clinical practice guidelines as standards of health care applicable to members and providers.

The IPA Quality Management Committees performs a review of nationally and locally developed guidelines and gives final approval of the adoption of all guidelines.

All clinical practice guidelines are based on scientific evidence, review of the medical literature, or appropriately established authority, as cited. All recommendations are based on published consensus guidelines that do not favor any specific treatment based solely on cost consideration.

The recommendations for care are suggested as guides for making medical necessity clinical decisions. Clinicians and their patients must work together to develop individual treatment plans tailored to the specific needs and circumstances of each patient.

Providers and members have the right to request a copy of a guideline that MSO, Inc. and VitalLinks, LLC. and MMSE have used to make a treatment authorization decision.

The guidelines utilized by the IPAs come from a variety of sources including:

The guidelines utilized by the IPAs come from a variety of sources including:

Centers for Medicare & Medicaid Services (CMS)
National Coverage Determinations
Local Coverage Determinations
CMS Benefit Interpretation Manuals
Medi-Cal Coverage Guidelines
Milliman Care Guidelines®
National Guideline Clearinghouse
Evidence in the peer-reviewed published medical literature

These guidelines are developed through:

Technology assessments and structured evidence reviews
Evidence-based consensus statements
Expert opinions of healthcare providers
Evidence-based guidelines from nationally recognized professional healthcare organizations and public health agencies

Shared decision-making aids
Providers can also utilize certified decision-making tools based on their specialty. These tools assist physicians in discussing treatment options with their members (conservative to invasive) and include information on risk and potential outcomes. Patient decision aids are available on the topics of maternity and labor/delivery; total joint replacement and spine care; end of life care; and cancer screening.