QualityPath® 

Our QualityPath initiative identifies doctors, hospitals, and clinics that provide high-quality care at a lower bundled price for services, meaning reduced out-of-pocket costs for you and your family. 

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Health Care Made Simple:

How You Benefit from QualityPath

  • Higher-Quality Care: QualityPath requires providers to take steps that lead to better patient results
  • Cost Savings: Reduced out-of-pocket costs for you and your family
  • Surgery & Test Warranty: For surgeries, a warranty protects you from the high cost of potential complications.
  • For tests, the warranty covers the need for repeating the same scan due to quality issues.
  • Better Patient Experience: With QualityPath, you have less paperwork. And for surgeries, you’ll be supported by a patient experience manager to act as your guide and liaison.

QualityPath for Surgery:

Knee and Total Hip Replacements

Patient Experience Manager: Your Guide to Better Care

Margie Czechowicz, RN, BSN, CCM
Patient Experience Manager

When you use QualityPath for surgery, you’ll be supported by a patient experience manager who can help you find a QualityPath provider, make appointments, transfer medical records, provide travel information, and answer questions.

For surgeries, call 800.223.4139.

Serious Savings on Surgeries with QualityPath

QualityPath covers the cost of the below:

  • Most care provided or ordered by your QualityPath surgeon to prepare for the surgery
  • The surgery and hospital stay
  • Follow-up visits and physical therapy provided by the QualityPath doctor, hospital, or health system
  • Most types of care related to the QualityPath procedure that is required during the 90-day warranty period
  • Most care for complications related to the QualityPath procedure that happen during the 90-day warranty
    period

The amount you pay may be different if you are in a plan with a health savings account (HSA), but you’ll still experience savings from QualityPath pricing.

Your employer may offer more incentives; talk to your Human Resources representative to learn more.

Benefit Details: Knee and Total Hip Replacements

Notification requirements:

Call The Alliance Patient Experience Manager at 800.223.4139 x6607 prior to scheduling services.

Services covered at the QualityPath level of benefits:

  • The initial consultation with the QualityPath surgeon
  • Pre-operative testing including:
    • Lab tests
    • X-rays & imaging
    • Pre-operative physical
    • Other tests that are determined to be medically necessary
  • One physical therapy visit done for the purpose of preparing for surgery
  • Joint class provided by the QualityPath provider
  • Services provided on an inpatient basis including:
    • hospital daily room charges & facility fees
    • surgeon’s fee
    • assistant surgeon fee
    • anesthesia
    • pathology
    • radiology charges associated with the procedure
    • physical therapy/occupational therapy other medical professionals, including hospitalists and other specialists as medically indicated
  • Post-operative care for 90 days after the surgery including:
    • lab fees to monitor therapeutic level of blood thinner as ordered by physician
    • Outpatient physical therapy performed by a the QualityPath provider, in a QualityPath hospital or clinic
    • Home health, including:
      • physical therapy
      • nursing care associated with initial assessment for physical therapy
      • nursing care associated with medication management, including lab fees

NOTE: please see warranty for information regarding complications.

Warranty:

Services under the warranty are covered under the QualityPath level of benefits. The warranty period begins the day of admission and continues through the 90-day episode-of-care. The warranty covers the following care related to the QualityPath surgery:

  • Hospital readmission and reoperation: during the 90-day episode-of-care
  • Other treatment of complications: during the 90-day episode-of-care

Patient requirements to maintain the warranty include:

  • Receiving all follow-up care from the QualityPath provider, excluding necessary emergency care.
  • Complying with all post-discharge instructions, including attending outpatient physical therapy sessions as well as completing the prescribed home exercises.

Exclusions:

The following services are not eligible for the QualityPath level of benefits. Check with your benefits administrator for coverage levels under the standard health plan benefits.

  • All services provided by a non-QualityPath provider (Outpatient physical therapy services and some home health care by an Alliance contracted provider may be covered at the QualityPath level of benefits. Check your SPD for details regarding physical therapy.)
  • Post-discharge care that is unrelated to the procedure
  • Skilled nursing facilities, unless for bilateral joint replacement surgery
  • Unrelated readmissions during warranty period
  • Coverage for the same procedure during the warranty period, when not due to complications related to the initial procedure
  • Care related to the procedure rendered outside the 90-day warranty period
  • Services provided by a QualityPath provider performed prior to member’s enrollment in the program
  • Rehabilitation services outside the physician care plan
  • Services provided inpatient unrelated to the QualityPath procedure
  • Durable medical equipment

QualityPath for Tests:

CTs, MRIs, and Colonoscopies

Serious Savings on Tests with QualityPath

Both CTs and MRIs are covered at 100% for patients enrolled in a traditional health plan. If a repeat scan is required due to poor quality, the 30-day warranty covers the cost of the second scan at 100 percent if performed by the same QualityPath provider. The amount you pay may be different if you are in a plan with a HSA, but you’ll still get savings from QualityPath pricing.

QualityPath covers colonoscopies that:

  • Are done on adults
  • Screen for or are related to colorectal cancer screening

You must use both a doctor and a clinic or hospital that offer QualityPath colonoscopies.

 

When Do You Plan to Use QualityPath?

To enjoy the full benefits of QualityPath, fill out the form below or call our patient experience team at 800.223.4139 before or shortly after you’ve scheduled your test.

  • For CTs and MRIs, you’ll still get QualityPath’s lower price if you forget to contact us via for or phone number;
    you may, however, miss out on other benefits
  • For colonoscopies, you must contact us via form or phone number to experience any QualityPath benefits

 

Benefit Details: CTs and MRIs

Notification requirements:

  • Patients are strongly encouraged to notify The Alliance prior to the scan appointment. Go to www.qualitypath.com/tellus to submit your information. Notification is not required to receive QualityPath benefit levels for CTs and MRIs.
  • Services covered at QualityPath level of benefits:
    • Services performed by the QualityPath provider during the patient medical service encounter, including but not limited to:
      • The CT or MRI and related services on a non-emergent, outpatient basis. The image must be the primary purpose for the encounter. (See the section “Triggering Service Codes” below for the list of eligible non-emergent outpatient CTs and MRIs.)
      • Drugs, biologicals, and radiopharmaceuticals that function as supplies and contrast agents and are administered by the QualityPath provider
      • All supplies
      • Ancillary services performed by the QualityPath provider
      • Guidance service
      • Image processing services
      • Observation services
      • Image reading and interpretation

    Warranty:

    Services under the warranty are covered under the QualityPath level of benefits. The warranty period begins the day of the scan and covers the following:

    • Reimaging, due to image quality, of the same site of service Triggering Service Code within 30-days when both episodes are provided by the same QualityPath designated provider.

    Patient requirements to maintain the warranty include:

    • Receiving all reimaging from the QualityPath provider.
    • Contact the patient experience manager at The Alliance at 800.223.4139 if your doctor asks for the scan to be redone because of the quality.

    Exclusions:

    The following services are not eligible for the QualityPath level of benefits. Check with your benefits administrator for coverage levels under the standard health plan benefits.

    • Emergent or inpatient care
    • When the image is performed as part of a surgical procedure or other more comprehensive service
    • Certain Specialized Imaging—those that may require special equipment in addition to CT/MRI machine, including:
      • Breast MRI
      • Cardiac MRI
      • Cardiac CT
    • All services provided by a non-QualityPath provider including but not limited to the administration of contrast materials.
    • Services provided by a QualityPath provider performed prior to member’s enrollment in the program

    Triggering Service Codes:

Benefit Details: Colonoscopies

Notification requirements:

You must notify The Alliance before your colonoscopy appointment for you to receive the QualityPath level of benefits. You may notify us in one of these ways:

  • Complete the online Tell Us form here. (Schedule the appointment with the QualityPath provider before completing the form.)
  • Send us the completed form available for download here (coming soon).
  • Call The Alliance Patient Experience Manager at 800.223.4139 x6607. (Call us if you have questions or if you need help scheduling your appointment.)

You must notify The Alliance before your pre-operative visit for it to be covered at QualityPath level of benefits. (Note – most patients are not required by the colonoscopy provider to have a pre-operative visit.)

Services covered at the QualityPath level of benefits:

  • Pre-operative visit
  • Facility (clinic or hospital) charge
  • Surgeon’s fee
  • Anesthesia
  • Pathology
  • Post-procedure care from the surgeon for up to 7 days after the procedure, including:
    • Follow-up visits
    • Pain management

NOTE: please see warranty for information regarding complications.

Warranty:

The Alliance must be notified of possible warranty services no later than 14 days after the date of the colonoscopy. Call 800.223.4139 x6607 if you have services that may apply to the warranty.

Services under the warranty are covered under the QualityPath level of benefits.  The warranty covers the following care related to the QualityPath colonoscopy:

  • Incomplete procedures including those halted due to poor preparation.
  • Emergent, urgent or inpatient care for up to 7 days following original procedure for gastrointestinal bleeding, abdominal pain and perforation.

Exclusions:

The following services are not eligible for the QualityPath level of benefits. Check with your benefits administrator for coverage levels under the standard health plan benefits.

  • Pre-operative lab work
  • Prep medications
  • Inpatient or emergency colonoscopies
  • Pediatric colonoscopies
  • Colonoscopies performed for reasons other than colorectal cancer screening or surveillance
  • Colonoscopies that are not the primary purpose of the visit
  • All services provided by a non-QualityPath provider
  • Post-procedure care that:
    • is unrelated to the colonoscopy
    • is not covered by the warranty
    • occurs more than 7 days after the colonoscopy
  • Pre-op visits or colonoscopies performed prior to The Alliance receiving notification of the appointments.

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