Basic Utilization and Case Management

Transcription

1 & CHAPTER 7 Basic Utilization and Case Management I Bartlett CHAPTER Learning, STUDY LLC REVIEW 1. Goal of utilization management is to see that each member receives the appropriate level of care at an appropriate cost with the appropriate providers of care. Reduce unwarranted practice variation by establishing parameters for cost-effective utilization of health care resources with I optimal outcomes. The monitoring of over and under utilization is important for quality of care. Manage utilization within clinical parameters in order to maximize resources, and contain cost while ensuring appropriate care is provided. Jones & Bartlett Measurements Learning, and Metrics LLC in Utilization Management Jones systems & NOT FOR SALE are OR important DISTRIBUTION for managing healthcare costs and NOT quality FOR of care. Utilization metrics can be calculated by dividing one whole number (e.g., total procedures) by another whole number (e.g., total member months) Some of the most commonly used basic measurements Bartlett Learning, - Per LLCMember Per Year (PMPY) - Per thousand members - Average length of stay (ALOS) - Per member or per unit Measures applied to units of utilization or to costs Adjusting Jones & for Bartlett time period Learning, measurements LLC 2. Utilization NOT FOR Varies SALE by Community OR DISTRIBUTION 3. Number of physicians in a particular area who are trained in a specialty as well as their preference for services; cause variations in healthcare services, i.e., An orthopedic surgeon may be trained to perform knee surgery by cutting the patient s knee open and fixing Jones & Bartlett the kneecap, Learning, requiring LLC an inpatient acute care hospitalization Jones & for NOT FOR SALE 3 days. OR While DISTRIBUTION another orthopedic surgeon may fix the NOT same FOR problem with a arthroscopic procedure requiring only outpatient surgery care that requires a 3 hour stay, and no inpatient hospitalization. ESSENTIALS OF MANAGED HEALTH CARE STUDY GUIDE: SIXTH EDITION 27 Copyright 2013, Jones &, an Ascend Learning Company

2 & Utilization tends to increase as services are more available in Jones & communities. Bartlett Learning, Markets LLC with an above average number Jones of hospital & Bartlett Lea NOT FOR SALE beds and OR physicians DISTRIBUTION tend to have higher rates of utilization. NOT FOR New SALE OR DI technology will drive utilization. It is important to manage new technology through national standards of care as well as the establishment of community healthcare trends. Though standard treatment approaches exist, such as clinical rning, guidelines LLC and published credible Jones utilization & Bartlett review manuals, Learning, LLC implementation and ongoing practice NOT FOR patterns SALE can vary. OR DISTRIBUTION Financial gain for payers, providers, and patients can play a role - Fee-for-service incentives reimburse providers for more care - Provider relations and practice patterns as well as, relationships and contracts, Jones add to the & complexity Bartlett Learning, of utilization. LLC This can create turbulence NOT in FOR a community e.g., If he s getting paid to do that, I should too! - Financial incentives under capitation can reward providers for under utilization that can result in less care - It is important to do claims review for proper coding of treatments Learning, and procedures. LLC Jones & Bartlett NOT FOR SALE Linking OR DISTRIBUTION evidence-based practice to pay-for-performance NOT FOR and SALE OR DI other payment methodologies should help monitor quality and promote evidence-based health care. 4. Benefits Design and Medical Utilization rning, Goal LLC is to create a product that can Jones successfully & Bartlett compete Learning, the LLC market, is important to quality of health care, and is appropriate utilization of resources. Cost-Sharing: This is often used by non-hmo payers to control premium inflation, and reduce unnecessary utilization. 5. Demand management is the early provision of less costly services and/ or self-care. It can be an Jones alternative & Bartlett to more costly Learning, healthcare LLC services. Nurse advice lines: NOT Are FOR usually SALE serviced OR DISTRIBUTION by RN s. They can be very useful by providing patients with access to advice on medical conditions, direction for medical care, health promotion activities, and preventive care. Self-care and self-evaluation programs: This entails the provision of information to members to enable them to provide care NOT FOR SALE for OR themselves DISTRIBUTION or better evaluate when they need NOT to seek FOR care SALE OR D from a physician. Shared decision-making programs: These programs involve making patients active participants in choosing their courses of care. rning, Personal LLC Health Record (PHR) and Jones personal & health Bartlett management Learning, LLC tools: These tools involve activities NOT like FOR tracking SALE and OR monitoring DISTRIBUTION 28 ESSENTIALS OF MANAGED HEALTH CARE STUDY GUIDE: SIXTH EDITION Copyright 2013, Jones Jones & Bartlett & Learning, Bartlett LLC, Learning, an Ascend Learning LLCCompany

3 & personal health measures, selecting health providers, managing health Jones dollars, & Bartlett and understanding Learning, and LLC influencing care treatments. NOT Healthrisk FOR SALE appraisals: OR These DISTRIBUTION are designed to elicit information I from a patient regarding certain activities and behaviors that can influence health status and treatment. - They are usually: Jones & Bartlett Risk-based Habit-based Learning, LLC NOT FOR SALE OR Utilization-based DISTRIBUTION 6. Categories of Utilization Management Prospective review: The review of cases before they happen. Concurrent review: The review of cases while they are active. Bartlett Learning, - Role LLCof utilization management Jones nurse: & Information gathering Telephone rounding Hospital rounding Criteria Review for LOS extensions Notification of medical director if required Jones Discharge & Bartlett planning Learning, and follow LLC up NOT - The FOR role SALE of the Medical OR DISTRIBUTION Director consists of the following: I Communication with physicians Daily review of utilization vs. exception review - Alternatives to acute care hospitalization include: Jones & Bartlett Learning, Outpatient Ambulatory LLC Surgical Centers (ASCs) Jones & Subacute Care: Skilled or Intermediate Nursing Facilities Step-Down Units Hospice Care Home Health Care Retrospective review: The review of cases after they are finished. Bartlett Learning, - Claims LLC Review: The examination Jones of individual & Bartlett claims Learning, for LLC improprieties or mistakes. - Patterns Review: The examination of patterns of utilization by payers to determine where action must be taken. 7. Case management refers to identifying and managing between the payer, provider, and patient either in a particular setting or across the healthcare continuum. 8. An NOT example FOR is inpatient SALE OR case DISTRIBUTION management... Form of UM that is not primarily focused on benefits determination Not limited to a defined set of chronic conditions May be part of discharge planning Jones & Bartlett May be Learning, applied to other LLC serious medical problems Jones with longer & NOT FOR SALE term OR implications DISTRIBUTION ESSENTIALS OF MANAGED HEALTH CARE STUDY GUIDE: SIXTH EDITION 29 Copyright 2013, Jones &, an Ascend Learning Company

4 & Case Management can begin at anyone of the healthcare point Jones & Bartlett of entry: Learning, LLC NOT FOR SALE - OR Emergency DISTRIBUTION Centers I - Hospital inpatient - Referral by provider There is a new focus on transition planning to reduce avoidable readmissions rning, Discharge LLC planning should begin at Jones the time & of Bartlett admission. Learning, LLC - Requires orchestration of services NOT FOR and benefits SALE coupled OR DISTRIBUTION with a reality-based clinical and financial plan. - Interdisciplinary: Should include all types of providers caring for the patient. 9. Determination of Coverage, Jones Medical & Bartlett Necessity, Learning, and Evidence-Based LLC Clinical Guidelines: High level definitions of medical necessity can vary based on plan design and may differ some from one benefits plan to another, although there is general consistency in its overall application by payers. Jones & Bartlett Typically Learning, defined as LLC items or services that may be Jones justified & as Bartlett Lea NOT FOR SALE reasonable, OR DISTRIBUTION necessary, and/or appropriate, based NOT on evidencebased clinical standards of care. FOR SALE OR DI Typically describe what is excluded from coverage, for varying reasons. One such reason might be that it is not considered medically LLC necessary. rning, Evidence-based means medical guidelines supported by peerreview and published research by appropriate medical researchers (e.g., universities). Evidence-based guidelines available through vendors and/or the AHRQ, and access is typically fully automated. 10. Basic UM is mostly about Jones benefits & Bartlett determinations, Learning, and the LLC means of applying those determinations NOT FOR is SALE through OR authorizations DISTRIBUTION for coverage. Different nomenclature for professional vs. facility authorizations - Pre-certification (Pre-cert) for facility-based authorizations - Pre-authorization (Pre-auth) for referral authorizations by a PCP in a managed care plan such as an HMO or PPO There are six types of authorizations: NOT FOR SALE - Prospective OR DISTRIBUTION - Concurrent - Retrospective - Pended (For review) rning, - LLC Denial (No Authorization) - Sub-authorization Authorization refers to either the managed care insurance company, a health plan, or a provider authorizing payment for a clinical 30 ESSENTIALS OF MANAGED HEALTH CARE STUDY GUIDE: SIXTH EDITION Copyright 2013, Jones Jones & Bartlett & Learning, Bartlett LLC, Learning, an Ascend Learning LLCCompany

5 & service. It is important to understand that it does not mean actually Jones permitting & Bartlett or prohibiting Learning, the healthcare LLC service. NOT An authorization FOR SALE system OR DISTRIBUTION allows the UM function of the plan to: I - Review a case for medical necessity - Channel care to the most appropriate location or provider It is the responsibility of participating Provider to authorize coverage for in-network care Jones & Bartlett It is the Learning, responsibility LLC of the Member/Patient to get authorization Jones & NOT FOR SALE for OR non-emergency DISTRIBUTION out-of-network care The Plan must define what services require or do not require authorization The Plan must define who can authorize a service Bartlett Learning, The LLC Plan must use published criteria Jones for procedures & Bartlett and Learning, high LLC cost testing Capture authorization data. 11. Authorizations affect claims differently by type of plan. HMO: Payment can be denied completely for services that are not authorized PPO Jones and Indemnity & Bartlett Plans: Learning, For a non-service LLC that is considered NOT a covered FOR benefit, SALE the OR amount DISTRIBUTION covered will be reduced I POS plans: If authorized by PCP, highest level of benefits, if non-authorized or goes out of network, benefits significantly reduced ESSENTIALS OF MANAGED HEALTH CARE STUDY GUIDE: SIXTH EDITION 31 Copyright 2013, Jones &, an Ascend Learning Company