Identifies
True or False - The CM follows HCC workflow if ONLY the 6 month spend is over threshold?
False - CM looks at both 6 and 12 month
If member identified for outreach but does not yet qualify as HCC what should the CM do?
proceed with standard CM outreach workflow
please consider: if monthly packet has not updated and you know that a member will probably become HCC in very near future, set DGA to check again after upcoming monthly packet drops
What provider should be outreached by care manager first?
provider that is providing specific care or on that is related to pertinent diagnosis.
When a care manager is preparing to do MD consult, CM should only use the 6 month spend?
True or False
FALSE - use both the 6 and 12 month spend
When should a case be sent to the TL for review?
200-300K
If case is primarily managed by another department the CM does not have to follow member for HCC
True/False
False - Traditional CM will follow HCC workflow and collaborate with the other department
what is the standard INITIAL outreach cadence for HCC?
2 attempts in 14 calendar days (1st within 7 days and 2nd within 14 days)
How often should a care manager outreach the physician?
minimum of every 90 calendar days
What dollar amount triggers case for MD consult?
>300K for either the 6 or 12 month spend
When should case be sent to Supervisor for review?
cases 300K or over
When another department is primary on case, how often do we need to collaborate with the primary department?
at least monthly, but can be more often based on clinical judgement or changes
If member is not engaged how often does the CM make outreach to member?
minimum outreach is every 60 days but can be more if clinical need
A care manager can NEVER outreach a provider more often that what is outlined in workflow? True/False
False - every 90 days is bare minimum. CM can outreach more frequently if clinically needed
What are other reasons that a care manager might send consult to MD? name at least one
RAP indicators, Care Gaps noted
When member spend trend falls below the HCC threshold, how many days should the CM monitor case?
60 days - making sure treatment plan is clear and member is compliant. End HCC workflow and transition to next level of support
Is there a specific DGA that needs to be entered on all cases followed for high-cost claims?
extra credit: if yes, what is that dga?
YES
D- Notified of high dollar claims from claims payment area
G- Determine if member needs to be followed for high dollar
A- Review all claim activity in ASD related to high dollar claim
For follow up calls to members, how many attempts are made each time outreach is needed?
CM attempts 1 call every 60 days. Second attempt is not needed unless clinical judgement deems appropriate.
What are 2 reasons that a care manager would outreach a provider sooner than recommended time?
multiple or new medications
· seeing new providers
· new prior authorizations
· multiple admissions
· no appointments with PCP.
Care conferences should be completed for any HCC that is over what dollar amount for 6 or 12 month spend?
800K -
If an acute episode caused the HCC threshold, what should a care manager look for before ending HCC workflow?
Member should be back to and maintained their baseline state of health. Ensure proper documentation reflects that you have reviewed.
What is the TAT for initial HCC review?
within 30 calendar days of assignment or within 30 calendar days of noting that the member meets HCC criteria
What are 2 reasons why a CM would outreach UTR member more often than the 60 days?
multiple or new medications
· seeing new providers
· new prior authorizations
· multiple admissions
· no appointments with PCP
Should the care manager send an MD consult if the member is inpatient and had an UM MD review?
No - case is sent after the member is discharged
True or False:
If member has a chronic condition or treatments that will remain ongoing and no additional gaps in care are noted the care manager cant stop HCC workflow based on their judgement?
FALSE - CM should discuss case with TL or supervisor to determine need for further reviews based on HCC threshold.