Evaluation and Contracting
How do we evaluate excellence? Optum's Clinical Sciences Institute, a group of more than 100 practicing clinical experts, helps develop the criteria to quantify excellence and stratify providers of complex health care. Evaluation criteria are reviewed and revised on a regular basis in order to incorporate current quality parameters and benchmarks as they relate to the applicable field of medicine.
Each medical center is evaluated annually. Although each condition-specific Centers of Excellence network has different criteria, general measures include:
- Volumes and outcomes of procedures
- Demonstration of best-practice medicine
- Quality of relationships with referring physicians and payers
- The makeup and stability of the program team
- Clinical research and results
- Program depth and breadth
- Treatment planning and coordination
- Quality of patient/family-oriented services
- Proof of a multidisciplinary approach to health care
Each year, Optum sends a survey to the medical centers and programs being considered for our Centers of Excellence networks. Upon receipt of a completed evaluation, the Clinical Sciences Institute conducts a detailed analysis of the program's responses to both clinical and administrative components and compares the responses to evaluation criteria. Programs that do not meet established criteria are rejected. Programs that do meet the criteria proceed to the contracting step of this process.
Optum requires that all participating programs in our Centers of Excellence networks complete the evaluation process on an annual basis. A change in network status may occur as a result of the quality review process and annual survey. This process ensures that our clients have access to only those programs that demonstrate continued clinical excellence in their field.
Participating Centers of Excellence programs must be willing to meet Optum's contracting terms. Rates need to provide economic value to Optum's payer clients, be global in nature, and be competitive with other network medical centers.
NCQA has reviewed and certified Optum's Credentialing and Utilization Management functions only. Date granted: 7/1/2014. Expiration date: 7/1/2016. For complete details on the scope of this review, visit www.ncqa.org.