Committee Structure

The American Specialty Health (ASH) quality improvement system is supported by a committee structure designed to integrate clinical and service operations, include contracted peer practitioner participation, and focus on improving the quality, efficiency, and effectiveness of ASH core processes. The following is a brief description of the primary committees that make up the quality improvement structure.

*Includes non-staff, participating practitioner(s) in voting membership.

The Board of Directors is accountable for the overall quality improvement system. The Board of Directors consists of the Chairman and CEO, President and COO as well as senior executives over each of the key clinical and operational areas of the company.

The QOC is delegated by the Board of Directors to oversee the quality improvement program, including adoption of policies, oversight of quality improvement initiatives, oversight of accreditation, and compliance with delegation and regulatory requirements. The QOC also reviews, approves, and oversees the Quality Improvement Program, Evaluation, and Workplan.

The CCC addresses and responds to new or revised expectations that routinely emanate from clients, legislative and regulatory agencies, accreditation organizations, or within the company. The CCC oversees corporate compliance with the above in support of existing business, new business, product development, and quality improvement initiatives. The CCC is responsible for developing and overseeing the QI Workplan.

*Practice Review Committee (PRC)

The PRC is responsible for providing peer review functions for credentialing, member grievances, and clinical services management and clinical performance management case review. The PRC makes decisions regarding Clinical Service and Clinical Performance Alerts, initial credentialing and recredentialing, individual practitioner education, Corrective Action Plans, terminations, and sanctions.

*Quality Improvement Committee (QIC)

The QIC is responsible for clinical policy and Clinical Practice Guideline development; peer review of credentialing denial appeals and first level termination appeals; clinical quality improvement activities; and analysis, evaluation, and recommendation regarding clinical quality improvement and initiative reports and satisfaction surveys.

*Special Investigations Unit Committee (SIU)

The SIU primarily monitors anti-fraud prevention and detection related to ASH, contracted practitioners, subscribers, enrollees, members, and employees to deter, identify, or detect incidents involving suspected fraudulent activity with regard to health care services arranged by ASH or other forms of fraudulent behavior.

*Evidence Evaluation Committee (EEC)

The EEC provides review of clinical evidence and research for the purpose of providing recommendations to clinical peer review committees relative to validity and applicability of evidence to best-practice and clinical protocols.

*Professional Affairs Health Care Advisory Committee (PAHAC)

Members of PAHAC are primarily representatives of national, state, or local associations or societies, academic institutions, and practicing clinicians, both participating and non-participating with ASH. The primary purposes of PAHAC are to solicit input, feedback, and recommendations to assist ASH in assessing quality improvement opportunities; review ASH Clinical Practice Guidelines and Criteria and make recommendations; review annual member and practitioner satisfaction surveys and applicable performance standards and make recommendations; contribute to ASH clinical and research initiatives; and collaborate with the PAHAC by attending PAHAC meetings and providing feedback.

*Contract Determination Committee (CDC)

The CDC manages issues of practitioner non-compliance with administrative and contractual guidelines and issues administrative Corrective Action Plans as necessary. The CDC also supports network management activities, practitioner agreement issues, and makes determinations of administrative practitioner terminations. Should the CDC identify potential quality of care issues, the issue is referred to the appropriate peer review committee.

*Administrative Review Committee (ARC)

The ARC is responsible for the review and determination of administrative (non-clinical) member and practitioner appeals, first level review of practitioner administrative termination appeals, and review of administrative policy.