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Utilization Management & Capitation Strategies - 2009 Edition
Apollo Managed Care Consultants, Feb 2009, Pages: 439
- Capitation Toolbox – Introduction; Behavioral Health Services; Capitation fundamentals; Direct access to specialty care (self-referral); Capitation Pros and Cons; Medical Loss Ratios; DRG payment systems; HMO Pools; Readiness Audit List; Levels of risk in capitation; Adverse selection; Medical group/IPA responsibility; Sponsor Discounts; Contracting Issues; The capitation contract; Physician and other ambulatory visits per year (average); Hospital Admission Rates and LOS – All Payer; Capitated HMO contract, Representative major financial pools;
Capitation expense allocations; Risk sharing arrangements (table); Flow of funds, algorithm – representational example; Capitation payment date issue in relation member enrollment; Hospital per diem rates/discharge timing considerations; Physician Encounter benchmarks; Critical success factors for managed care organizations, checklist; Capitation rate example; Health Plan Operational Metrics; Physician Encounter benchmarks; Specialty Physician Payment Systems; ‘Per Case’ or global package pricing strategies; Contact capitation; Specialist capitation; example strategy/plan; Pay for Performance (P4P) programs; Ancillary provider contracts; Medicare ‘Fraud and Abuse’ /Health care compliance; Medicare is targeting costly physicians
- Utilization/Resource Management Toolbox – Introduction to Utilization Management; Guidelines; Effect of guidelines on care; Medical necessity – What is it?; Case Law Citations – related to medical necessity; Length of Stay Guidelines/DNR orders; Unplanned readmissions w/audit form; Tracking new federal regulations;
- Utilization/Resource Management Program; Program elements; Referrals within the medical group; Medical necessity; Outreach; Communication concerning UM policies to patients and the public – example; Program elements; Report requirements; Pharmacy Management; Documentation requirements; Utilization Resource Management Department; Discharge delays;
Basic elements of an UM plan (refer to UM Plan model in addendum); Consultations vs. referrals; UM Department staff and staffing; UM Committee; UM Policy and Procedures – example for medical group/IPA/MSO; The Review Process; Assignment of Case Numbers P&P;
- Benefit and eligibility determinations – Identification card; Financial Responsibility Guarantee Form; Eligibility and Benefits Verification – P & P; Precertification/Certification Worksheet; Eligibility FAQs;
- Case or Care Management (CM)???Introduction; CM program savings; Hospital UR/Case Management – functions; CM roles and responsibilities; Primary Case Manager – Role/Responsibilities; Hospital Case Manager – Role/Responsibilities; Specialty Case Manager – Role/Responsibilities; Specialty Case Management; P & P; Specific disease examples for case management services; Criteria for Social Service/Counseling Management; SCM case closing; P & P; SCM discharge form example; Hospital Case Manager UM Variance Reports, example list; Preadmission Review/Precertification or ‘Precerts’; Hospital charges for non-covered services; Preadmission case management screening tool;
Procedure for prospective review; Prior authorization check list form; Diagnostic referrals; Diagnostic radiology referral form; Procedures for ‘Patient Care Plan’ form completion prior to review; Authorization Request Form; Request for Authorization - additional mental health services; form; Request for Authorization to provide additional services; form; Physical Therapy note; Request for continuation of services; form; Referral Authorization form; Review Worksheet form; Reviewer Communication Form to Requesting Provider;
Observation status for acute care - P & P;
- Review Process – Role of the physician advisor, Concurrent and Retrospective; Concurrent review; policy & procedure; Concurrent review, work sheet form; Concurrent review check list form; Authorization review work sheet form; Length of Stay and next review date assignment; ‘stickey’ example; Specialty pre-admission authorization; Blended Specialist-Primary Care Physician for a Qualifying Patient; Primary physician notification; P&P with form;
Retrospective review, policy; Inappropriate admission - change in status; Discharge planning; policy and procedure; Authorization of special services; Periodic review of pre-authorization policies – example; Specialty pre-admission authorization; Primary physician notification; P & P with form; Authorization approval notification form; Authorization denial notification form; Outpatient surgical authorizations; procedure; Complications following non-covered services, policy; Custodial care, definition; Audit for Access Time to Specialty Care Following Primary Care Referral.
- Ambulatory Services Management - The Minnesota Medical Practice Model; Out-of-Pocket (OP) Patient Expenses; Outpatient surgical authorizations, procedure; Podiatry Services;
- Referral Authorization Strategies – ‘Passthroughs’ or ‘Automatic’ Approval or ‘Direct Access’ – example list; Streamline referral process; ‘Open Access’ + example P & P for Chemical Dependency; Delegation of UR function to selected physicians; Specialty physician delegated procedure list, by specialty; Urology referral check list; Orthopedic referral checklist;
- Emergency Services; P & P; Alternative care or redirection of care; References and resources related to ER services; ‘Out of Area’ Care; P & P; Procedure for ‘out of Network’ Arrangements for care; Letter/Contract to ‘Out of Network’ provider; Payments for Emergency Services to Non-contracted Providers – California Law
- Home Health Care; Home Health/Hospice Case Management, Policies/procedures; JCAHO Emergency Preparedness for Home Care; Home Health/Hospice - Case Management; Homebound criteria; Common reasons for failure/lack of use of home health services, Skilled Home Nursing Care; Home Nursing for Ventilator or C-PAP Patients;
Physician directed homebound program, Home visits by physicians following hospital discharge; Care Plan Oversight; Home health care referrals, P & P, Termination of home health care services, Home Health Aides/Assistants; Caregivers; Home health infusion services, Oxygen coverage guidelines, Home Safety Visit Checklist, Hospice; Eligibility Requirements; Hospice benefits; Hospice care in a SNF; Karnofaky Performance Scale; Home Health Care for Psychiatric Services;
- Skilled care Services; Skilled Nursing Facility, payment issues; Levels of skilled care;
- Durable Medical Equipment ; P & P; DME form;
- Denials, Appeals, Redeterminations, Grievances – Introduction; Insurance denials for alcohol-related emergency treatment; Denial and Appeal Process, policies and procedures; Medicare + Choice and Medicare time frames for appeals; Work sheet for physician reviewer; Standard denial letters; Denial Letter to provider, example format; Denial Letter; commercial member format, examples; Denial Letter; Medicare HMO member format; Denial letter, SNF benefits; Denial retraction letter format; Denial letter, exhaustion of SNF benefit, commercial; Acknowledgment of receipt of notice, SNF benefits denial; Notice of non-coverage; fax sheet example; Appeals process, policy and procedures; Appeals Committee; Complaints/grievance reporting vis a vis provider contracts; Appeals Review Status Tracking Form; Grievance tracking; References & resources re: appeals, denials, grievances; Denial rate – examples; Claims letter denying payment, non-covered services, to com. Member; Claims letter denying payment for non-covered services, to provider; External Reviews;
- Discharge Planning - Discharge Planning; Policy & Procedure; Stratis Health (MN QIO) Discharge Planning Quality Resources Kit (links); Notes
- Annual U/RM Work Plan – Special Studies; Program Surveys; Radiology performance profile for medical groups; Tracking Hospital and SNF Admissions; Statistical reports, hospital bed days and other benchmarks
- Algorithms – Prospective and concurrent review; Preadmission evaluation; Electronic referral process; Ambulatory Care Referral process; Alternative UM process; Automatic or pass-through procedures; External provider authorization process; Preadmission ER Evaluation; Utilization/Case Management, Behavioral Health; UM Case Management; Med/Surg, OB & ICU; Ambulatory Care Authorization process
- Integrated Quality Management/Improvement Strategies – Building a foundation for Quality constructs; Where should a higher-risk procedure be performed in a specific patient or population of patients?; Introduction to the QA/QM/QI Department; Integration of Utilization/Quality Management Programs; QM/UM overlap examples; ‘Pay for Performance’ programs; QI/QM Clinical Indicators/Performance Goals Standards list; Case Mix
Adjustment for provider profiles; Hospital/SNF QA Screens; Provider Sanctions and Fines: QI Committee; Fine Notification Form; QM staffing ratios
- Administrative/’Back Office’ Strategies, Policies and Procedures – Staffing ratios for a MSO; Case contracting;
Claims processing; Submission of encounter data and claims; Coordination of Benefits; Third party liability; IBNR;
Operational standards (List); Committees; New Technology Assessment, P & P; Medical Records – Issues in managed care contracts; Non-contracted or ‘Out of Network’ Claims;
Hospital care performance standards, Hospitalist/attending physicians; Physician management services, conference time/phone calls; Primary physician selection; Sign Language Interpreter services; Sanctions and Fines – Utilization Management, P & P; UM Committee Meeting Attendance Requirements; Social Work Services; Quarterly Primary Physician Dinner Meeting Attendance Requirement;
Balance sheet & Income Statement Ratios; Transitional Care Center policy; Transportation, medical; UR Organizations, fiduciary responsibilities; Waiver of Co-payments – P & P; Worker’s Compensation; ERISA
- Education Strategies – Education for Patients and Providers – Why???; Emergency care brochure; Authorization process brochure; Speed up the authorization process by ...; The Big Secret; Hospitalist care – explanatory brochure
- R/UM Staff Job Descriptions and Effectiveness Evaluations – Medical Director or Chief Medical Officer; UM Physician Advisors/Directors job descriptions; Clinical Director, UM; Managed Care Coordinator; UM; Coordinator (Nurse reviewer); Concurrent review nurse coordinator; Care Coordinator/Case Manager; Managed Care Technician I and II; Pharmacy Benefit Manager;
UM Staff Training and job standards; UM Reviewer Evaluation, P & P; Assessment tool for UM staff; Utilization review, Inter-rater Reliability Evaluation P & P; Audit Tool; Audit of UM Authorization and Denial Services with tools and forms; Audit - hospital 1 to 2 day admission tool
- References and resources – an extensive section, alpha listed by topic
- Appendices – Utilization Management Program model; UM financial data collection - example formats; Medical Policy/Medical Management Committee; Inpatient Days Prior to a Surgical Procedure – Policy; Payment denials for surgical errors; Surgical Length of Stay ‘Benchmarks’ or Targets; Medical LOS examples – refer to the following LOS by DRG table; Managed Care Legal Resources on the Web; Medicare+Choice, synopsis of medical management rules and regulations; Demographic cost factors, senior, by class; Key Contacts at CMS; Hospital care ‘length of stay’ targets, by age range; Frequency by Diagnostic/Procedural Group, Acute Hospital Care, California HMO data; Hospital Days, Physician Encounters and Ambulatory Visits; LOS targets by DRG; Claims management consultants - resources
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