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What to Do When an IHN-CCO Member Misses Appointments

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Providers must notify IHN-CCO when a member has missed at least two primary care appointments with no effort on the member’s part to reschedule. Scheduled and missed appointments should be documented in the member’s file with the PCP. Any letters sent to the member by the PCP should also be sent to IHN-CCO for documentation purpose. If the member continues to miss appointments, the provider has two options.

Provider Options for Dismissing a Member

In the first option, the provider can contact IHN’s Customer Service and request intensive case management (ICM) for the member. The provider should be able to discuss the needs of that specific member with a health care guide and/or case manager. IHN will work closely with the provider, the member and their caseworker (if applicable) and/or other appropriate persons who may be able to help resolve the issue.

In the second option, the provider can choose to dismiss the member if the provider has previously notified IHN’s Customer Service of the missed appointments. The letter of dismissal to the member should be sent to IHN’s Customer Service and should explain, as applicable:

  • the specific reason for the dismissal;
  • that the Provider will provide emergency care only during the 30 days following the dismissal;
  • if the dismissal is only for the Provider or for the entire clinic;
  • that the member should contact IHN to arrange to choose a new PCP.

Update: Please include two identifying points of data for the member, such as date of birth and member ID. This will help us expedite the process and eliminate a follow-up call from us for clarification.

Based on the facts of the case, IHN will coordinate with the member to choose a new PCP, or if the member is not engaged in this process, IHN will reassign the member to another provider.

In Some Situations, Providers Cannot Term Members

There are some situations that do not qualify for terming a member for missed appointment. Providers can request that a member be reassigned to another provider if the provider is unable to resolve the issue after taking steps to deal with the issue and it is not solely based on the following:

  • Having a physical or mental disability
  • Adverse change(s) in member’s health
  • Excessive or lack of utilization of services
  • Diagnosis of end stage renal disease (ESRD)
  • The member exercising his/her option to make decisions regarding his/her medical care with which the provider disagrees
  • Exhibiting disruptive or uncooperative behavior, including threats or acts of physical violence, which is a result of the member’s special needs.

These termination restrictions also apply to situations when a member displays behavior issues. If a provider is unable to resolve an IHN-CCO member’s behavior issues after taking steps to deal with the behavior, or the behavior is severe enough to jeopardize the provider’s ability to furnish services to the member or his/her assigned membership, the provider may request that the member be reassigned to another provider.

Provider Responsibility

Providers have a duty to provide medical care to a patient until the proper termination of that relationship. When a physician dismisses/withdraws from a patient who is in need of continuing care at that time, the physician must take the following steps:

  • Give reasonable notice of the intent to dismiss/withdraw.
  • Provide the patient and the plan with a reasonable time to find alternative care (no less than 30 calendar days).
  • Continue to be available during this 30-calendar day time period to treat the patient for emergency care until the date indicated in the notice.
  • The provider must notify the member in writing of the intent to dismiss the member from that provider’s care, with the reason why, and the provision for 30 days at least of continued care.

References

OAR 410-141-0220 (5) C,c

PHPs shall have written procedures and a monitoring system for timely follow-up with members when participating providers have notified the PHP that the members have failed to keep scheduled appointments. The procedures shall address determining why appointments are not kept, the timely rescheduling of missed appointments, as deemed medically or dentally appropriate, documentation in the clinical record or non-clinical record of missed appointments, recall or notification efforts, and outreach services. If failure to keep a scheduled appointment is a symptom of the member’s diagnosis or disability or is due to lack of transportation to the PHP’s participating provider office or clinic, PHPs shall provide outreach services as medically appropriate.

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