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Utilization Management & Capitation Strategies - 2011 Edition
Apollo Managed Care Consultants, Feb 2011, Pages: 504
A 504 page toolbox of UM model policies, procedures and plans that ‘work’ with P & Ps for traditional, streamlined, open access and other cost-effective management strategies. Contact capitation and other variations of traditional capitation compensation strategies are detailed. Case management and quality management programs. Resources include utilization management program example format, audit policies and forms, contract analysis formats, numerous forms benchmarks, job descriptions, legal resources and case citations, links to authoritative national guideline resources, references and a glossary of managed care terms
This manual has been developed to provide a model for methods to ‘manage care’ more effectively and efficiently. The relatively unmanaged, unstructured and unsupervised medical care system of two to three decades ago has evolved to require expert medical management, structure based on a clearly defined objective rationale and sophisticated oversight. Understanding the clinical ‘decision support criteria’ or ‘review criteria-guideline’ approach to either implementing or judging appropriateness and medical necessity is essential to be a viable participant in the business of patient care. Early recognition, appropriate and necessary evaluation and treatment, and needed follow-up care are the keys to a quality-based, cost-effective model of care for any condition.
“These guidelines are an educational tool designed to assist practitioners in providing appropriate care for patients. They are not inflexible rules or requirements of practice and are not intended, no should they be used, to establish a legal standard of care. … The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician” (or other care provider) “in light of all the circumstances presented. Thus, an approach that differs from the guidelines, standing alone, does not necessarily imply that the approach was below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations on available resources or advances in knowledge or technology subsequent to publication of the guidelines. However, a practitioner who employs an approach substantially different from” nationally accepted “guidelines is advised to document in the patient record information sufficient to explain the approach taken. The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis, alleviation and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. It should be recognized; therefore, that adherence to these guidelines will not assure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care.” [selections within quote marks by the American College of Radiology, preamble to individual guidelines, 2002)
Each example policy and procedure/review criteria/guideline throughout this manual should be reviewed by the medical policy (or similar) committee and modified or adapted as appropriate to fit local circumstances. It is strongly recommended that all applicable documents that will be used to manage medical care in the organization be sent to affected providers for review and comment prior to implementation. This will always promote an understanding of the policy, procedure, criteria or guideline, avoid compliance issues, and frequently improve the document by added input.
This manual does not provide legal counsel or advice. There is no uniform universal contract language. Applicable laws vary from state to state and in some cases, from locality to locality. Every physician requires the availability of expert legal and accounting advice to manage the business aspects of their practice.
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