Mandatory Benefit Management Program (BMP)

Transcription

1 Mandatory Benefit Management Program (BMP) The BMP Care Management Program is a mandatory program for subscribers enrolled in the medical plans. Pre-certification must be obtained whenever your physician or other providers recommend any of the following services: hospitalization skilled nursing facility admission hospice and home care inpatient mental health and/or chemical dependency treatment major diagnostic medical tests (MRIs, CT scans, Mylegrams, MRAs, and PET scans) Failure to follow the guidelines of the BMP Care Management Program can result in a benefits penalty. The BMP Care Management Program can: help reduce the cost of care while preserving quality and access to care provide health services in settings that best meet your individual treatment needs acquaint you and your family members with alternative treatment options In order for you to receive full medical plan benefits, it's important that you follow BMP's Care Management Program guidelines. When the above services are performed out-of-network, you should request that your out-of-network provider initiate the pre-certification process. However, you will want to make sure that the precertification was obtained. Failure to obtain pre-certification for the aforementioned services will result in a $500 penalty. When the above services are performed in-network, the in-network provider should contact BMP to obtain pre-certification. BMP's hours of operation are 8:30 a.m. to 4:30 p.m. Eastern Time, Monday through Thursday and 9:00 a.m. to 4:30 p.m. Eastern Time, Friday. Calls to the toll-free number, , are answered directly by a patient service representative. The BMP toll-free number also appears on your subscriber identification card. The patient service representative will ask you, a family member, or a provider for specific information needed to start the process (patient's name, date of birth, admitting doctor's name, etc.). If you call after normal business hours or on a weekend, you will receive a message requesting you to leave the information. Following the initial call to the patient service representative, your case is then referred to a BMP care manager, who is a qualified health professional. The BMP care manager will call your doctor to discuss the details of your treatment plan. Based on the information your doctor provides, the BMP care manager will evaluate the medical appropriateness of the proposed care. BMP generally completes its review within 24 hours, assuming all necessary information is available. It can, however, take up to ten days to get a pre-certification processed. To avoid problems, you will want to start the process no later than ten days prior to a procedure/admission. You may wish to encourage your doctor to call BMP directly to initiate the care management process. In the majority of cases, when a doctor initiates the call, the process can be completed and a decision made with just one phone call. This easy-to-use program helps you make informed health care decisions: 1

2 Medically Necessary/Appropriate Care Medically necessary or appropriate care is a specific health care or hospital/treatment facility service that is necessary for the treatment or management of a medical symptom or condition and is the most efficient and economical care that can be safely provided. The fact that a physician may prescribe, order, recommend or approve a service or supply does not, of itself, make the service or supply medically necessary. The claims administrator determines whether a service or supply is medically necessary or appropriate. Hospital pre-admission certification - All non-emergency hospital admissions (excluding delivery admissions) are to be reviewed and certified before you enter the hospital. When your doctor recommends admission to a hospital, you or a family member are expected to call BMP at least ten days prior to the admission or service date. In cases that do not permit a ten day precertification, BMP must be notified as soon as possible. The care manager will call your doctor to discuss the details of your treatment plan. BMP generally completes its review within 24 hours, assuming all necessary information is available. If the admission is considered medically appropriate, a reasonable length of stay is assigned. If the inpatient stay is not considered medically appropriate, the care manager explains different treatment options and discusses available outpatient settings with you and your doctor. During the certification process, it will be determined if the facility meets the appropriate licensing and accreditation requirements of the plan. Post-emergency admission - In an emergency, there's no time to waste. It's very important to get treatment started first, and then call BMP within 48 hours of the admission. You or a family member must also call within 48 hours of the admission if you've been admitted without a pre-admission review or if you were transferred from another hospital. The same process as hospital pre-admission certification is used to assess the appropriateness of the admission and assign a reasonable length of stay or explain treatment options if admission is not considered medically appropriate. Inpatient Mental Health and/or Chemical Dependency Treatment All non-emergency admissions are to be reviewed and certified before you enter the facility. When your doctor recommends admission to a hospital, alcohol or drug rehabilitation facility, you or a family member is expected to call BMP at least ten days prior to the admission or service date. In cases that do not permit a ten day pre-certification, BMP must be notified as soon as possible. The care manager will call your doctor to discuss the details of your treatment plan. BMP generally completes its review within 24 hours, assuming all necessary information is available. If the admission is considered medically appropriate, a reasonable length of stay is assigned. If the inpatient stay is not considered medically appropriate, the care manager explains different treatment options and discusses outpatient settings with you and your doctor. During the certification process, it will be determined if the facility meets the appropriate licensing and accreditation requirements of the plan. Concurrent review - When you or a family member is hospitalized, your condition is monitored by the care manager in consultation with your doctor and the hospital. BMP, along with your physician, evaluates the need for continued hospitalization beyond the initial length of stay. If hospitalization is no longer necessary, BMP works with you, the doctor and hospital to discuss alternative settings such as the outpatient department, home health care, skilled nursing care, or hospice care. Non-emergency diagnostic radiology services - All non-emergency diagnostic testing must be reviewed and pre-certified. When your doctor recommends one of the diagnostic medical procedures in the following list, you or a family member must call BMP prior to the procedure. (It is recommended that the call be made at least ten days prior to the procedure.) The care manager will call your doctor to discuss the details of your treatment plan and the diagnosis. The review is usually completed within 24 hours, assuming all necessary information is available. If the diagnostic testing is considered medically necessary or appropriate, you may schedule the procedure. If it is not considered medically necessary or appropriate, the care manager will discuss different treatment options with you and your doctor. Refer to the following list of diagnostic medical procedures that require pre-certification. 2

3 Diagnostic medical procedures requiring pre-certification: o CT scans (Computerized Tomography) o MRIs (Magnetic Resonance Imaging) o Mylegrams o MRAs (Magnetic Resonance Angiography) o PET scans (Positron Emission Tomography) Each time your care includes any of the above procedures, it is important to remember to contact BMP for the appropriate pre-certification. Failure to obtain the necessary approvals may result in denial of payment. Pre-certification and Utilization Review Penalties Please note: Plan benefits may be lowered or denied if you fail to follow the pre-certification and utilization review guidelines. Specifically, If you use out-of-network providers and fail to obtain hospital pre-admission certification, postemergency admission review, or non-emergency diagnostic radiological tests, your inpatient and/or outpatient hospital and/or physician benefits will be reduced by $500. OR If BMP determines that the treatment is not medically appropriate and you choose to be hospitalized or have the procedure, your medical plan may provide no benefits for this treatment. You could be responsible for paying the entire cost of the inpatient hospital stay, diagnostic radiology services and physician(s) charges. BMP s Second Opinion Program Your doctor and BMP will reach an agreement about proposed surgery or treatment most of the time. However, there may be times when there is disagreement, i.e., where the need for a hospital stay is not clearly indicated, the benefit of surgery does not outweigh the risks, or the appropriateness of another treatment option is not clear. For those times when a second opinion examination is needed (because BMP and your doctor can not reach agreement) or is desired by you, the care manager will help you select a consulting physician in your area who can provide a second opinion. Take as much information as you can to the second doctor, including the results of any x-rays or laboratory tests, and be sure to ask about anything that you don't understand. The more you understand about your treatment plan, the more comfortable you will feel about your decision. The second consulting physician's fee will be covered up to your current benefit level, as well as other related services that are necessary, such as x-rays and laboratory tests. If the second consulting physician does not recommend the same treatment as the first physician, you may also request a third opinion from another consulting physician. The third physician s fees and services would also be covered up to your current benefit level. After the BMP professionals have carefully considered all of the information, you will be notified by priority mail regarding the outcome of the review. Your physician and the hospital will also receive notification. If you are notified that your proposed treatment cannot be certified as medically appropriate, chances are your doctor will already have made arrangements for other, equally effective medical care. This is because other options - options that involve less risk and inconvenience for you - will have been explored. If You Disagree with BMP 3

4 An appeal process gives you the opportunity to have your case reviewed if you disagree with a BMP determination. You can also use an appeal to present new information that may have a bearing on the case. Either you or your physician, acting on your behalf, can ask for your case to be reviewed if you disagree with BMP s determination. You must request an appeal within 30 days of receiving BMP's determination. The request can be verbal or in writing and should provide any additional supporting information not previously considered in the decision. If the patient is the requester, the patient will be advised that supporting clinical information must come from the facility or provider involved with delivering the plan of care. The appeal will be directed to BMP's Appeal Coordinator who will send an acknowledgment of receipt of the appeal to the requester within three calendar days of receipt. The Appeal Coordinator forwards all clinical documentation to the appropriate medical specialty team. The medical specialty team will make a recommendation to Global Crossing and, generally, Global Crossing will act on that recommendation. Based on Global Crossing's decision, the patient and the provider will be advised of the appeal determination within 30 days of receipt. You may also contact your Human Resources Benefits Representative regarding other appeals for review that may be available under the Employee Retirement Income Security Act of 1974 (ERISA). BMP s Coordinated Care Management Program This program is designed to assist the patient and families who are in need of support in the event of a chronic, terminal, and/or catastrophic health problem. A Registered Nurse Case Manager works with you, your family, your doctor(s), and any appropriate community health care professionals to coordinate the care and services you need. The Case Manager provides education specific to your health care needs, referrals to community resources, and monitors your health status. Current programs include: Healthy Baby Connection (a high-risk pregnancy program), HIV+/AIDS, Catastrophic Case Management, Asthma and Diabetes Disease Management, Acute Rehabilitation, and Medical/Behavioral Health Case management. The goal is to enhance your knowledge and ability to effectively manage your disease and improve your quality of life. The Case Manager is an advocate to you and your family and can assist in navigating the complex health care environment. Know All the Facts about BMP Please be aware that you may be responsible for all or part of the cost of hospital and physician charges if you: do not notify BMP and receive approval through the pre-certification process for out of-network hospital or rehabilitation facility admission in a non-emergency - $500 penalty; do not notify BMP within 48 hours of an emergency or transfer admission from another hospital or rehabilitation facility to an out-of-network facility - $500 penalty; do not notify BMP and receive approval through the pre-certification process for an out-ofnetwork non-emergency diagnostic radiology procedure - $500 penalty; choose to be admitted to the hospital or rehabilitation facility after BMP has recommended outpatient treatment - no coverage; choose to stay in a hospital or rehabilitation facility longer than your doctor and BMP determine is medically appropriate - no coverage beyond stay deemed appropriate. 4

5 Remember - not calling BMP when required or receiving treatment BMP considers medically inappropriate can result in a financial penalty to you. 5