Medical Management. At a Glance 2. When to Notify Medical Management 3. Procedures Requiring Predetermination 4. Care Management Services 5

Transcription

1 Medical Management At a Glance 2 When t Ntify Medical Management 3 Prcedures Requiring Predeterminatin 4 Care Management Services 5 Abut Identifi TM 5 Cmplex Care Management 6 Maternity Prgram 8

2 Medical Management 2 At a Glance The Medical Management Department f the MedStar Select Plan is respnsible fr managing health care resurces. T this end, the department: Authrizes cverage f certain prcedures Perfrms predeterminatin reviews Authrizes ut-f-netwrk and ut-f-area care Apprves member transfers t ut-f-netwrk facilities Offers care management services fr medically cmplex cases Prvides access t special needs services Prvides access t health management services fr members with specific chrnic diseases Administers member and prvider surveys and assessments Fr questins and additinal infrmatin, Medical Management can be reached at Mnday thrugh Friday, frm 8 a.m. t 4:30 p.m.

3 Medical Management 3 When t Ntify Medical Management Prviders must call the Medical Management department t authrize cverage fr the services, prcedures and equipment shwn n the Quick Reference Guide. The Quick Reference Guide can be fund at Services may include but nt be limited t the fllwing categries: Out-f-area and/r ut-f-netwrk care fr a member, including the transfer f a member frm ne hspital t anther Cverage fr certain specific prcedures Sme durable medical equipment (DME), including specialty wheelchairs and scters knwn as Pwer Mbility Devices (PMDs) Any inpatient admissins t acute care hspitals, skilled nursing facilities, rehabilitatin facilities, and lng-term acute care centers. This enables the MedStar Select Plan t identify members special needs and crdinate their care. In sme cases, clinical staff may help arrange care in an alternate setting.

4 Medical Management 4 Prcedures Requiring Predeterminatin Predeterminatin is the prcess the MedStar Select Plan uses t review specific prcedures r treatments t determine whether they will be cvered. A cmplete list f prcedures that require predeterminatin is available nline at. If a prvider wuld like a predeterminatin review, a written request must be submitted t: MedStar Select Plan Medical Management Department One Chatham Center 112 Washingtn Place Pittsburgh, PA FAX: The prvider must include the medical justificatin that will be cnsidered in the apprval r denial f the prcedure. If cverage is denied, the prvider may appeal the decisin by fllwing the appeal prcess that is included with the letter f denial.

5 Medical Management 5 Care Management Services Care Management is available t all MedStar Select Plan members wh require a multidisciplinary apprach t their care. Registered nurses supprted by pharmacists, dieticians and ther prfessinals take the lead in assisting members with needs spanning varius aspects f scial services and the medical cmmunity. Patients are identified fr care management a number f ways: Referrals thrugh hspital Transitin Care Crdinatrs (TCCs) Based n MyHealth Questinnaire results (health assessment) Stratificatin thrugh Identifi Referrals frm primary care physicians (PCPs) Analysis f medical claims data t identify patients with multiple chrnic cnditins Abut Identifi TM Identifi TM is an analytics engine and wrkflw platfrm prviding the MedStar Select Plan with the hlistic, integrated infrmatin necessary t drive imprved utcmes acrss all settings f care. It cmbines the leading cmmercially available cntent with prprietary rules and mdels, and leverages the unique data and access affrded by a prvider-led apprach. Features: Integrates smart analytics t avid cnflicting patient utreach generated thrugh stratificatin prcess Includes predictive mdeling data t identify high risk readmissin and supprt preventive actin Prvides single surce f infrmatin fr all member utreach Huses a library f hundreds f custmizable assessments that drive cnsistent prcess, with decisin-tree lgic fr fllw-up Custmizable wrkflw t supprt lcal care prcesses (wrk list ruting, apprvals, etc.) Real-time alerting with data frm ADT Real-time interface t claims systems fr managing enrllment, benefits, authrizatin and claims detail Huses cmprehensive clinical data abstract f relevant patient facts f selfreprted, claims, pharmacy and lab data Supprts medicatin review thrugh cmpletin f a cmprehensive medicatin review

6 Medical Management 6 Cmplex Care Management At MedStar Select, Cmplex Care Management crdinates services fr members with cmplex cnditins and helps them access needed resurces. Many times, Cmplex Care Management members have a clinically advanced illness and multiple cmrbid disease states and they need help navigating the medical care delivery system t receive apprpriate care and services. At the same time members needing cmplex case management may have experienced a critical event r diagnsis that requires extensive use f resurces and assistance fr a shrt perid f time. Sme f these diseases and/r situatins are: Asthma CHF COPD Crnary artery disease Depressin Diabetes Hypertensin Frequent visits t the emergency rm Three r mre hspital admissins in six mnths Hw are members identified? Members with cmplex needs are identified thrugh a variety f surces, including: Claims r encunter data related t specific diagnses, high-cst members and members with a high utilizatin f services Pharmacy data Hspital discharge data r infrmatin cllected thrugh Utilizatin Management prcesses, including precertificatin requests, cncurrent reviews, prir authrizatin reviews, and reviews f hspital admissin and readmissin data Members can als be referred t Cmplex Care Management thrugh: Practitiners The 24-hur nurse advice line (health infrmatin line) The staff managing the member as part f disease r health management prgrams A discharge planner Utilizatin Management staff Member, family, r ther caregiver; self-referral Frm ancillary prviders, behaviral health prviders r behaviral health managed care rganizatins, pharmacists, the Medicatin Therapy Management Prgram, disability management prgrams, ther internal departments, emplyer grups, r staff frm cmmunity agencies Is patient participatin vluntary? Patient enrllment in the Cmplex Care Management Prgram is vluntary and members may decide t dis-enrll at any time.

7 Medical Management 7 What services are prvided? The prgram puts yur patients in tuch with a care manager wh will wrk with them t develp a care plan aimed at helping the patient set gals t adhere t their physician s treatment plan and imprve their health, based n accepted clinical practice guidelines. Specific assistance ffered: An evaluatin f the member s cultural and linguistic needs, preferences, r limitatins An evaluatin f the member s caregiver resurces that are in place t supprt him r her with apprpriate care and decisin making An evaluatin f available benefits and assciated financial burdens, as well as what may be needed t supprt the member s treatment plan and identified needs Develpment f a care plan that: Addresses the identified needs; Includes lng- and shrt-term gals; Establishes a time frame fr re-evaluatin; Identifies resurces t be used and at what level f care; Prvides cntinuity f care planning and determines the assistance that is needed; and Uses a cllabrative apprach that identifies wh will be included, such as family, practitiner, pharmacist r cmmunity-based services. Identificatin f barriers t the member s meeting gals r cmplying with the plan, which includes such factrs as pr cmpliance t treatment plan, lack f understanding, nt ready t make a change, financial hardships, pr supprts, transprtatin issues r fragmented care Helping the member t develp a self-management plan which may include hw he r she will mnitr the disease, use a practitiner-prvided symptm respnse plan, cmply with prescribed medicatins and attend practitiner visits Fllwing member s prgress against the case management plan that was develped fr the member, including prgress tward vercming identified barriers, any adjustments t the care plan and fllwing the self-management plan Crdinatin f care fr multiple services, including inpatient, utpatient, and ancillary services Facilitating access t care Establishing a safe and adequate supprt system thrugh interactins with the member and/r applicable caregivers Hw can yu refer a member fr Care Management Prgram? If yu wuld like t refer a member fr Cmplex Care Management r if yu have questins abut the prgram, call us at Representatives are available Mnday thrugh Friday frm 8 a.m. t 5 p.m.

8 Medical Management 8 Maternity Prgram The MedStar MyHealth Maternity prgram ffers members a persnal Maternity Care Manager t help identify, plan and achieve the healthy lifestyle that is s imprtant during pregnancy. The prgram delivers resurces, infrmatin and assistance t help members and their babies have the healthiest start pssible. A MyHealth Maternity Care Manager wrks with members frm the mment they enrll. Over the curse f their pregnancy, members receive timely phne calls and cmmunicatins t help them stay well, understand their prgress and access supprt if experiencing any cmplicatins as they prepare fr the birth f their baby. Hspital c-pays are waived fr prgram participates wh deliver at a hspital in the MedStar Select Prvider Netwrk, and ther financial rewards fr participatin are available. Fr infrmatin n enrlling ne f yur patients, call Care Management at