Unit A
Preservice, concurrent, and retrospective
What are the 3 types of reviews completed by the UM department ?
A utilization management program used in hospital and health plan setting based on evidence based guidelines- including care pathways to aid in decision making
What is MCG?
This review of services/treatments prior to the service date is considered the prior authorization. Accounts for the highest volume of requests reviewed. Includes planned inpatient hospitalizations or procedures, outpatient services and home health items, services and/or equipment.
What is Pre-service review
› Focuses on identifying and removing any barriers to a smooth, safe and timely discharge to home or to a less intense inpatient setting.
› Helps ensure that individuals can quickly and safely transition to home or a lower level of care without unnecessary delay.
What is Discharge Planning?
An eligibility file containing member enrollment information
What is the 834?
Enhanced standards and quality of care by providing disease management interventions to the appropriate patient group
Multi -disciplinary collaboration
Reduction in LOS
What is benefits to the provider?
Utilization Management Component
Standards and Guidelines
Internal Quality Improvement Process
Clinical Information
Agreement and Collaboration with Clients– e.g., Delegation
Denial Notices
Privacy and Confidentiality
Policies for Appeals
UM Program Structures
Appropriate Handling of Appeals
Clinical Criteria for UM Decisions
Satisfaction with the UM Process
Communication Services (access tostaff)
Emergency Services
Appropriate Professionals
Triage and Referral for Behavioral
Healthcare
Timeliness of UM Decisions
Delegation of UM Activities
What is NCQA Utilization Management Standards and Guidelines?
•CMS Managed Care Manual
•State Insurance Regulatory Bodies
•Individual Health Plans and Payor Requirements
•Specialty Medical Society Guideline
What is Other Standards for UM Procedures?
Right Care
Right Place
Right Time
What 3 UM Rights?
ICD-10
CPT Codes
HCPS
What are codes needed to submit PA?
The evaluation of the appropriateness, medical need and efficency of health care services, procedures and facilities according to establishned criteria or guidelines and under the providions of an applicable health benefit plan?
What is Utilization Management?
Reduce over- and under utilization
Increase defensibility and reduce risk
Aligh stakeholders
Support Performance management
What are reasons we use MCG?
This occurs while treatment is in progress and usually starts within 24-72 hours of admission to a hospital. Also focused on skilled nursing facility, residential BH care, intensive outpatient BH care and ongoing ambulatory care. Focuses of the review are to track utilization of resources and the patient's progress, and to reduce denials of coverage after the treatment is complete. Comprised of Care Coordination, Discharge planning, and Transition of Care
What is Concurrent review?
The process of verification of application of clinical standards required per contact
What is IRR?
Financial requirements (such as coinsurance and copays) and treatment limitations (such as visit limits) imposed on mental health or substance use disorder (MH/SUD) benefits cannot be more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical/surgical benefits in a classification
What is MH parity?
•PA list includes services and procedure requiring review prior to the member receiving care.
•Is plan specific.
•Published on SHP website and in member benefit materials.
•Designed to eliminate barriers for members with chronic conditions/special health care needs
What is a Prior Authorization?
Focus on health treatments that a provider would supply to a patient based on sound clinical judgement. The activity must be used to evaluate, diagnose, or treat an ailment, injury, disease, or its symptoms.
What is Medical Necessity?
This is performed after treatment is complete. Its purpose is to assess the appropriateness, effectiveness, and timing of treatments, as well as the setting in which they were delivered. Post service review of services that require prior authorization is limited by exception reasons. If an exception is granted the same criteria and plan benefits and guidelines are applied to the request or case as would be applied for pre-service requests.
What is a Retrospective review?
These professionals make decisions to increase efficiency in providing health care services.
What is a Care Manager?
Different timeliness standards may apply between payor contracts
What is TAT - Turn-around-time
Medicare Special Needs Plans
LTSS
CCO / ACO
What are models of Managed Care?
All physicians, in-or out-of network, call a medical director to discuss a case that may have been denied. or any case for which they have questions
What is peer to peer ?
•A request for a health care product or service where application of the time frame for making routine or non-life-threatening care determinations:
a. could seriously jeopardize the life, health or safety of the member or others, due to the member’s psychological state;
OR b. In the opinion of a practitioner with the knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is subject of the request.
What is an expedited request?
• Per Thousand Members Per Year (PTMPY) Medical/Behavioral Services–Inpatient Admissions–Inpatient Days–SNF Admissions–SNF Inpatient Days–Home Health Visits–ER visits–OP visits
•Pharmacy Utilization–Generic prescription rate–Adherence rates as measured by timely refills
•Other Per Member Per Month (PMPM) or Per Year (PMPY)–PCP visits–Specialty Referrals–High cost imaging studies (MRI, PET scans)–Costs per episode of care
What are Common UM Metrics for Program Evaluation ?
What are frequent denial reasons?