On an annual basis, Horizon NJ Health conducts a provider profile review and awards those primary care practitioners who meet select criteria with a financial quality bonus. The amount of the bonus is based on the provider´s individual performance, in comparison with select quality measures and the overall goals of Horizon NJ Health.
The measures within the profile are developed from the most recent National Committee for Quality Assurance´s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) process that uses Emdeon´s MedMeasures Software (except for the Lead and Emergency Room measures). In addition, we look at Emergency Room rate per thousand members as a proxy for access to primary and urgent care. Company goals are based upon requirements identified in the New Jersey State Medicaid Contract. A provider´s individual performance is then analyzed in comparison to the provider network as a whole.
Each provider´s profile information is based strictly on claims and encounter data, not on an actual review of medical records. Our reimbursements focus on areas that show a potential for improvement that we believe could enhance quality outcomes for our members.
In addition to awarding providers who meet the program´s criteria, Horizon NJ Health also reviews each provider´s performance against an overall average to identify those who need additional outreach and education to improve their results.