How To Manage Health Care Needs

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1 HEALTH MANAGEMENT CUP recognizes the importance of promoting effective health management and preventive care for conditions that are relevant to our populations, thereby improving health care outcomes. Each year CUP completes an analysis of high volume diagnoses and procedures to determine whether existing programs continue to be relevant to current members. CUP s services include several Health Management programs designed to monitor the health care delivered to our members by assessing for trends, identifying medical necessity, and evaluating the appropriateness of care. Recognizing the importance of managing members health care needs in this manner, CUP has established several Health Management programs that include the following components: Case Management and Care Coordination Individuals with Special Health Care Needs (ISHCN) Disease Management for High Risk OB and Chronic Pain Direct Link for Prenatal Care EPSDT and Immunizations Hospital Discharge Planning / Concurrent Review Patient Review and Coordination (PRC) Referral Management Utilization Management The structure of the Health Management programs allows for early involvement in assisting members with health care needs and for interventions to promote positive outcomes. Care management is a fundamental component because it can improve quality of life, increase member satisfaction, promote compliance with recommended medical regimens, and foster member self-determination. CUP s mission statement and key core values are consistently reflected throughout the Health Management Program. Improved quality of care and service, cost control and appropriate crisis intervention are key components of our Program. In addition, meeting the specific medical and psychosocial needs of our members prospectively aids in the overall reduction of health care cost, increased member participation in self-care, and satisfaction with their health status. Medical decisions in the Health Management programs are primarily based on InterQual criteria, which are nationally recognized standards of medical practice, and on the utilization management standards developed by the National Committee for Quality Assurance (NCQA). The goals of CUP s Health Management programs are to: Determine medical necessity, appropriateness and efficiency of health care services, appropriate level of care and discharge planning needs; Coordinate transitions in care Continually monitor, evaluate and optimize use of health care resources; Monitor utilization practice patterns of participating practitioners, hospitals and ancillary services; Identify and assess the need for case management through early identification of high or low utilization of services, high cost, chronic or long term diseases;

2 Promote and provide health care education to both member and providers in accordance with local, state and national standards; Identify events and patterns of care by which outcomes may be improved through efficiencies in utilization management, and institute actions to improve performance; Ensure timely responses to appeals and grievances; Review utilization data that identifies over and underutilization practices, and identify and implement programmatic improvements that enhance appropriate utilization; and Provide primary linkage with community resources with emphasis on assessing available services, determining eligibility for these services and coordination of available services. Case Management and Care Coordination: CUP s Nurse Case Managers coordinate resources and create flexible, cost effective care options for at risk members on a case-by-case basis to facilitate quality and individualized pursuit of health. The case managers work collaboratively with all members of the healthcare team, including discharge planners at the affiliated hospitals and skilled nursing facilities. The Medical Director and Health Programs Manager will be involved in overseeing these case management functions. CUP s Case Management Program is designed to: Coordinate cost-effective services; Monitor care, to provide easily accessible care without access barriers as related to the member s available benefits; Apply benefits appropriately and coordinate care with institutional, Provider, and vendors. Promote early and intensive treatment intervention in the least restrictive setting; Provide accurate and up-to-date information to providers regarding member evaluations; Create individualized care plans, which are revised as the member s healthcare needs change; Utilize multidisciplinary clinical, rehabilitative, and support services; Arrange broad-spectrum appropriate resources for members; Deliver highly personalized case management services; Grant adequate attention to member satisfaction; Uphold strict rules of confidentiality; Provide ongoing case management program analysis and development; Encourage collaborative collegial approaches to the case management process; Promote the case management program s viability and accountability; and Protect member rights and encourage member responsibility. CUP s Health Management Department assigns a Nurse or Behavioral Health Care Manager to members identified as needing case management services. The Case Manager will: Gather the appropriate information to complete a case assessment. This includes an evaluation of the member s related clinical, psychosocial and socio-economic factors as well as the member needs and treatment goals. Access the member s individual and community-based resources to assist in determining interventions. Develop an individualized care plan in conjunction with the health care team, responsive to the needs and goals of the member. Implementation of needed services in a cost effective and organized manner. On-going evaluation of the care plan in relationship to the desired member outcome. Coordinates appropriate educational sessions and encourage the member s role in self-help.

3 Evaluation of Case Management interventions to promote quality service and evaluation of the effectiveness of Case Management relative to the desired and/or optimal outcomes. Monitor the progress toward member s achievement of treatment plan goals in order to determine an appropriate time for the member s discharge from the case management program. Assure that members with special health care needs have direct access to specialists. Most members appropriate for case management services are identified through pre-authorization review, concurrent review, member/provider referral, new member outreach screening/ assessment, or claims. These members at times require more comprehensive care coordination and member/provider interactions. They are often assisted through complex treatment plans. Members are assigned a specific nurse or behavioral health care manager and have their contact information for easy access. Direct Link: DIRECT LINK is an integral piece of prenatal case management within our OB program. It offers assistance to obstetrical providers caring for CUP members throughout their pregnancy. A CUP nurse care manager will work directly with providers and their staff to provide additional resources for the at risk members. In addition to formal case management of these identified members, the nurse care manager coordinates necessary services for CUP members and assists with linking members to community resources such as transportation to and from appointments. A referral form should be completed on all new pregnant CUP members. Use the DIRECT LINK Referral Form for provider staff to copy, complete and FAX to the CUP nurse care manager at Disease Management: Disease Management programs for High Risk Pregnancy and Chronic Pain stratify, monitor, educate and assist in managing varying levels of need identified in these disease specific populations. These programs are designed to assist members with better understanding of their condition, update them on new information and help them manage their disease. The Disease Management programs are also designed to reinforce the members treatment plan to improve outcomes. Members are notified when they qualify to be in one of these programs and can opt out if they choose not to participate. PCP s are informed of member participation. The programs provide the following services: Support from our nurses and other health care staff to assist members in understanding how to manage their health conditions. Periodic health status review Educational and informational materials to assist members in understanding and managing their health conditions. If you would like to enroll a patient in one of these Disease Management programs, please contact CUP s Health Management department at

4 EPSDT (Early and Periodic Screening, Diagnosis and Treatment) and Immunizations: CUP actively promotes the health and well-being of all children enrolled in CUP and ensuring access to preventive care is one of CUP s primary goals, including: Education on the availability and importance of these screening examinations; Publication and distribution of screening policies for practitioners via preventive guidelines. PCP s are encouraged to provide EPSDT and Preventive Health care to their members. EPSDT includes regular check-ups to make sure children get the preventive care they need. These check-ups or wellchild exams include: Full scope medical exam Immunizations Complete health and developmental history Lab tests Screens for vision, hearing, dental/oral health, mental health, and substance abuse Sports physicals are often the only time adolescents present in the clinical setting and thus represent a unique opportunity to increase adolescent well-care exam rates. If all elements of care for a qualifying adolescent Well-Child (EPSDT) exam are completed, providers can and should bill for an adolescent Well- Child exam. This may also increase the clinic and provider HEDIS quality ratings for this measure. To view the Preventive Health Guidelines click here To view Clinical Practice Guidelines click here Hospital Discharge Planning / Concurrent Review: Hospital and Skilled Nursing Facility (SNF) services frequently constitute a considerable portion of the managed care budget. Review and coordination of these services therefore warrant careful management. Management of these services begins with the PCP s notification process of the reason for planned inpatient admission, specialists involved, and the estimated length of stay and the notification of the facility to be used on a referral notification form. The estimated length of stay criteria are based on the 10 th Percentile of the Western Region Length of Stay Manual and InterQual. Concurrent review is a key component of hospital and SNF utilization management. CUP s Nurse Care Managers are Washington State Licensed RNs, responsible for review and monitoring of all admissions for: Appropriate level of care; Severity of illness; Intensity of services being provided; and Anticipated date for transfer to the next appropriate lower level of care.

5 Concurrent review is conducted using InterQual criteria. Elective admissions are reviewed beginning on the day after the admission and as the patient s condition indicates, until the patient is transferred to the next appropriate lower level of care. Emergency admissions are identified as quickly as possible and reviewed as the patient s condition indicates, beginning on the day of admission if possible. For all admits, a review is done prior to the anticipated discharge date. Any stay where the intensity of service indicates that the patient could be transferred to a lower level of care should first be clarified with the facility care manager or the admitting physicians to the treatment and disposition plans. If there still seems to be a delay in transferring the patient to the next appropriate lower level of care, physician-tophysician communication may be warranted to resolve the situation. Discharge planning, provided by the hospital staff, should begin on the day of admission and includes an assessment of living conditions and family support systems. The admitting physician and hospital staff facilitates discharge planning by documenting the anticipated disposition (home, rehab, etc) and any therapies or DME which may be needed for the patient upon discharge. This information is then coordinated by the hospital staff responsible for making arrangements for these services in a timely manner. Social or financial situations which may complicate or delay discharge or impede patient care are addressed. The CUP UM RN will work with the hospital staff as necessary to assure appropriate discharge arrangements. During the process of concurrent review, a patient may be identified who has been admitted with injuries or diagnosis which are complicated or where follow-up intervention will be required. Any of these cases may be referred to CUP s Case Management Program (head trauma, spinal cord injury with neurological deficit, brain tumor, certain types of cancer, AIDS, or is respirator dependent, etc). CUP s Care Management Team will research the case and consult with the providers, while coordinating with the PCP to develop and assist in the implementation of a treatment plan. Authorizations to Skilled Nursing Facilities (SNFs) are generally given in one-week increments, but may be as short as a few days depending on the diagnosis and treatment plan. Authorizations for SNF services are given according to levels of skilled care being provided. A network physician must perform an initial physical examination within 48 hours of the patient s admission to the SNF. After the initial physical exam, Physician Assistants or Nurse Practitioners may alternate visits with the supervising physician. Regulations require that a physician see skilled level patients at least once every 30 days. More acute conditions may require more frequent physician visits. At the time of a patient s admission to a SNF, CUP s Health Management Department will provide the SNF nursing staff CUP network contacts to assist the nursing staff when ordering specified services. The Nurse Case Manager performs reviews of SNF members weekly at a minimum (more if required by intensity of services being done), evaluating the level of care, and services being rendered. Patient Review and Coordination (PRC): Patient Review and Coordination (PRC) is a health and safety program. CUP s PRC program is modeled after the HCA program. In the PRC program, members who show excessive or apparent inappropriate use of services, or who demonstrate high risk behaviors, are limited to just one emergency department (for non emergent services), one pharmacy, one PCP, and one controlled substance prescriber (which is often the PCP). Providers should contact CUP s Health Management Dept. at (360) if they have any CUP patients who may benefit from PRC.

6 Authorization Management: CUP requires prior authorization for selected covered benefits and service, and does not process retroactive requests. Please consult CUP s referral authorization page for criteria and prior authorization form located on our website. Authorization requests can be faxed directly to CUP s Health Management Dept. at FAX # , toll free FAX # Members and providers are notified of the approval or denial by letter. Letters to members and providers note that the criteria used to make the decision for that authorization request are available upon request. The member is informed of their right to an appeal process in the event a request for treatment has been denied and the member is dissatisfied with the decision. The following sources have been used to establish the medical guidelines and criteria that are utilized in the Referral Management process: Medically necessary and appropriate services as defined by State and Federal contractual language and/or regulatory WAC s and rules; InterQual - nationally recognized medical criteria Standard and customary treatment and/or medical literature and consultation consensus developed from local practice patterns and approved by the Medical Advisory Committee; Health Plan Policy and Procedure Guidelines developed and approved by the Medical Advisory Committee; An authorization request may be denied for any of the following reasons: Not medically necessary; Not a covered benefit; Not a covered service Benefit has been exhausted; Services can be provided by the PCP or within the primary medical group; Experimental or investigational care or services are being requested; Practitioner is not within network, and these services are available within the network; No referral notification/authorization has been requested, i.e. the member has self-referred for the services. There are three time lines for CUP s review and authorization or denial of referral requests: Emergent Request: Emergency services do not require prior authorization. CUP defines a medical emergency condition as: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part (42 CFR (a)). These services will be paid if the member is eligible at the time the service was delivered. Urgent Requests: This request indicates an urgent or acute clinical condition that requires care in the next few hours. Urgent services indicate that medical symptoms require immediate attention but the condition is not life threatening. It is CUP s goal to process and communicate the requests for urgent care within four hours of receipt. Prior Authorization and Pre-Certification Requests: Decision determinations are made within two business days after receipt of complete information.

7 Smoking Cessation: Members may contact their PCP to discuss options to help them quit smoking. Members may also contact Washington State Tobacco Quit Line at: QUIT-NOW or (English) NO-FUME (Spanish) Individuals with Special Health Care Needs (ISHCN): CUP has a process in place for outreach to new members each month. A screening tool is utilized to identify members with possible special needs. ISHCN can include members that could also be classified as having catastrophic or chronic/long term care coordination needs. These members are then contacted by a care management team member to identify and assess specific health needs. When a member is identified as an ISHCN the member s PCP is contacted and information provided regarding the initial assessment. The PCP then must conduct an evaluation of the member and document an individualized treatment plan within the member s medical record. This treatment plan is to be kept in the member s medical record and updated as needed. It should also be sent to CUP for purposes of Case Management and Care Coordination activities. You will find our Care Management team accessible and ready to help you with this population. Utilization Management: Utilization Management (UM) is an integral component of CUP s Health Management Program. The purpose of Utilization Management is to monitor care across the health care continuum, assessing trends and specific incidents of under and over utilization of medical care, medical necessity, and appropriateness of care. Utilization Management evaluates medical appropriateness and cost effectiveness of health care services delivered to the membership by using accepted, standardized criteria. CUP s Medical Advisory Committee (MAC) is responsible for the oversight and direction of Utilization Management. The membership of MAC is comprised of board certified practitioners and CUP staff. The Medical Advisory Committee responsibilities include: Development, approval and annual review of the Health Management Program; Development and approval of medical criteria and protocols to evaluate the Appropriateness of services by utilizing actively participating practitioners; Reviewing and resolving utilization and benefit issues including but not limited to denials and appeals as related to utilization decisions; Reviewing new technology requests; Reviewing and analyzing data on outcomes and trend studies; Monitoring compliance with external regulatory and accreditation bodies; Reviewing and approving reports from delegated entities; Reviewing utilization decision turnaround time compliance; Education of practitioners and members assigned to managed care practices; and Evaluation of the program achieved through tracking, trending, and analyzing data for under and over utilization of appropriate medical care, member and practitioner satisfaction