Emergency Room Utilization and Lock-in Program

Transcription

1 Emergency Room Utilization and Lock-in Program 1

2 Emergency Room Utilization Kentucky Medicaid patients utilize the ER at rates that far exceed the national averages for utilization. 1 In 2013, UK s ER had 15,963 Medicaid recipients with a total of 26,244 visits. About 70% had one visit while 104 (0.65%) had more than 10 visits to the ER. 1 2

3 Emergency Room Utilization cont. The ER Navigators and ER Coordinators are working to reduce these numbers by educating our members on proper ER utilization and the programs and services available here at Passport to assist them with their health care needs. The ER Navigators are the nurses in the ER making face-to-face contact with the members, giving them information on the programs and services available to them in an effort to reduce the non-emergent ER utilization. The ER Coordinators receive daily (Norton and Sts. Mary and Elizabeth) or weekly (Hardin Memorial) reports on ER utilization of Passport members and use telephonic outreach and mailings to educate members on proper ER utilization and refer them to the appropriate programs/departments to assist them with any barriers to care. 3

4 Emergency Room Lock-in In compliance with Regulation 907 KAR 1:677, Passport Health Plan did implement an Emergency Room (E.R.) Lock-in program to address excessive utilization of E.R. services by engaging primary care providers, emergency room providers and the health plan The Lock-in Program is a requirement of the Kentucky Department of Medicaid Services (DMS) 4

5 ER Utilization vs. ER Lock-In Any member with high ER utilization can be referred to Wil and Andrea for telephonic outreach. A member can also be referred to the ER Navigators, Tammi (Kosair Hospital) Robin (Sts. Mary and Elizabeth Hospital), Teresa Duncan (Hardin Memorial Hospital), and Mary Ann (University of Louisville) for face-to-face outreach A member cannot be referred to Lock-In, they must first meet the criteria 5

6 Regulatory Program Components ER Lock-in Criteria Members MUST satisfy the following in 2 consecutive 6 month periods: Four (4) hospital emergency department visits for a condition that was not an emergency medical condition; OR Receive services from at least three (3) different hospital emergency departments for a condition that was not an emergency medical condition 6

7 Regulatory Program Components (cont.) Member Restrictions under ER Lock-in: Member will be assigned to a designated facility The Lock-in member is assigned to a specific facility per the DMS regulation. But if the member goes to ANY ER for a nonemergent condition they could be held liable for the services rendered. The member should be considered assigned to the ER Lock-In Program NOT the hospital. 7

8 Regulatory Program Components (cont.) Exclusions per Regulation 907 KAR 1:677: Members who reside in a facility reimbursed pursuant to 907 KAR 1:025 or 1:065 or in a personal care home (i.e. long term care facilities) Members under the age of eighteen (18) years old Members who utilized the ER to treat complex/chronic medical conditions (i.e. pregnancy, diabetes, asthma, behavioral health) Members who receive: services through home and community based waiver program in accordance with 907 KAR 1:145, 1:160, 1:595, 1:835, 3:090, or 3:210 (i.e. Michelle P Waiver Program) Hospice services in accordance with 907 KAR 1:330 8

9 Diagnosis What is a non-urgent diagnosis? Kentucky DMS has a table of Emergency Medical Conditions ( 3c337eadcd68/0/lockintableofemermedlcond618kar1677.p df) Any diagnosis NOT on the DMS list of Lock-in Table of Emergency Medical Conditions is considered nonemergent Diagnosis is based upon the DISCHARGE diagnosis 9

10 ER Claims Report 10

11 ER HELP Passport will administer ER HELP (Health Education and Lock-in Program) to members in lock in ER Coordinator will outreach to lock-in members to educate them on ER use and available resources ER Coordinator will send a warning letter followed by telephonic outreach to members who are nearing lock-in status The Lock-in program is not intended to penalize or punish the member. The program is intended to: Reduce inappropriate use of health care services; Connect members with case managers and/or disease managers who can identify reasons for overuse of medical services and provide education on their health care needs; Enhance quality of care by developing a stable patient-provider relationship. 11

12 ER Lock-in Warning Letter Members are sent an ER Lock-in warning letter if within a 6 month period they have four (4) nonemergent visits to the ER Members are given a courtesy call if within a 9 month period they have five (5) non-emergent visits to the ER 12

13 ER Lock-in Notification Letter The Lock-in Notification Letters are mailed around the 10 th of the month before the effective Lock-in month. The letters notify the member that they are in the ER Lock-in program, their assigned hospital and their appeal rights 13

14 PCP Lock-in Notification Letter Each PCP with Lock-in members on their panel is mailed a letter notifying them that their patient is Locked-in and a claims report with the nonemergent ER visits We mail the letter to the PCP so that they can go over the report with the member and address any issues and/or concerns with their health 14

15 Provider Responsibility Verify member eligibility via NaviNet Determine if the member is in lock-in status If the member is in lock-in: Triage to evaluate for urgent/non-urgent condition If non-urgent, inform the member of financial responsibility for services performed after triage Obtain member signature on Acknowledgement of Responsibility for Payment prior to services being rendered Provider may bill the member for services beyond those of triage for non-urgent diagnosis Passport will reimburse the provider for triage services ONLY The provider may appeal a denied claim for services rendered to a lock-in member 15

16 Contacts Name Title Contact Anna Page Maureen Ritchie Director Manager Wil. Armour ER Coordinator Andrea Bell ER Coordinator Tammi Hiemer Robin Higdon ER Navigator (Kosair) ER Navigator (Saints Mary & Elizabeth Hospital) Mary Ann Martin ER Navigator/Clinical Health Educator (University of Louisville Hospital)