Chapter 2. Medical Management and Quality Improvement

Transcription

1 Medical Management Overview...3 Introduction...3 Objectives...3 Important Program Points...3 Prior Authorization...4 Overview...4 MedicareBlue PPO Covered Items and Services...4 Medical Policy...5 Prior Authorization...5 Services for which prior authorization is recommended...5 Types of Prior Authorization...6 Durable Medical Equipment (DME) Prior Authorization...6 HCPCS E Eligible or Non-covered DME...7 Prescription or Doctor s Order...7 DME Waiver Requirement...7 DME Upgrade Claims Submissions...7 Case Management...8 Overview...8 Available Services...8 Home Health Care Prior Authorization...9 Skilled Nursing or Extended Care Facility Admission Prior Authorization...9 Hospice Care...10 Referrals to Case Management...10 Admission Notification, Plan of Care Review, Continued Stay Notification...11 Information Needed for Admission Notification...11 Discharge Date Notification / Length of Stay Review...11 Discharge Call Process...11 October

2 Chronic Care Management...12 Heart Failure Program...12 Referrals to the Heart Failure Program...12 Quality Improvement...13 Basic Elements of a QI Program...13 Collaboration with MedicareBlue PPO Program...14 Accessibility Requirements...14 Medical Record Keeping Policies...15 Minimum Requirements...15 October

3 Medical Management Overview Introduction As part of your participation agreement with MedicareBlue PPO, you have agreed to comply with medical management programs administered by MedicareBlue PPO. These medical management programs are designed to ensure that the treatment members receive is reimbursable according to the medical necessity guidelines in their contracts. In addition, we review and investigate new procedures/services for coverage determinations. Medical management programs also ensure the most cost effective and appropriate use of the health care delivery system. These programs include: Prior Authorization of selected procedures, services, supplies, and drugs Admission Notification for inpatient admissions Case Management Heart Failure Program To make utilization decisions, MedicareBlue PPO uses written review criteria based on sound clinical evidence. The criteria used to evaluate individual cases are available upon request for your review. The structure of the Heart Failure Program is based on the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult. Objectives Medical management programs are designed to ensure appropriate utilization of health care resources. Objectives of the programs are to: Promote efficient use of health care resources Define and agree upon appropriate standards of care Important Program Points The following points pertain to all of the medical management programs. Any medical necessity denial determination may be discussed with a physician reviewer by telephone. Any services denied using the MedicareBlue PPO medical necessity guidelines cannot be billed to the member/patient unless you have specifically notified the member/patient prior to the October

4 service being rendered that the service is medically unnecessary and will not be covered, and the member/patient has agreed in writing to pay for the service. The medical management process is a review for medical necessity only. Payment for services is still subject to all other terms of the member s benefit package as determined by the Centers for Medicare & Medicaid Services (CMS). Therefore, denials may occur because a service is not covered under the benefit package. We recommend that you contact Provider Service to verify coverage, benefits, contract eligibility and limitations for all patients. Service representatives will also verify which medical management procedures apply to a patient s contract. Providers will continue to be held financially liable for services that are determined to be not medically necessary and/or investigational during a review or an audit process even though prior authorization and/or admission review has been requested, or is not required. Prior Authorization Overview The purpose of prior authorization is to review services prior to being rendered to determine if the services are medically necessary and contractually eligible. Prior authorization is recommended for some services to help providers and members avoid unexpected expenses, benefit reductions, and/or claim denials. The prior authorization process determines eligibility for medically necessary services, supplies, or treatment. The reviewer uses medical policy guidelines and other criteria, and member contract language to assist in determining if benefits are available for the request. Authorization for a service, device, or drug does not in itself guarantee coverage but notifies you if, as described, it meets the criteria for medical necessity and appropriateness. If prior authorization is not obtained, a retrospective review may be performed after the claim is submitted to determine whether the services, supplies, or treatment were medically necessary and/or were a benefit of the member s contract. We will evaluate your description of services and medical documentation and will make a medical necessity determination once all the necessary medical information is received. MedicareBlue PPO Covered Items and Services MedicareBlue PPO is required to cover all services covered by Original Medicare on a national basis. Uniform local coverage determinations will be applied across the region. October

5 Policies from the following entities will be used as the standard: Carrier/Part B: Wisconsin Physicians Services Medicare Review System (WPS) DME MAC Jurisdiction D: Noridian Administrative Services Intermediary/Part A: Noridian Administrative Services (NAS) RHHI: Cahaba Government Benefits Administrators MedicareBlue PPO is not required to follow Local Medical Review Policy (LMRP) issued by other Carriers, Intermediaries and DME MAC s operating within the Region. Questions about whether a particular service will be covered by MedicareBlue PPO may be directed to Provider Services. See Chapter 1 Contact and Administrative Information. Medical Policy Medical policy is available at It contains details on new medical health policies and/or updates to existing medical health policies, explains coverage criteria, and includes coding and prior authorization recommendations. Prior Authorization Follow the guide below to determine if a prior authorization (PA) is recommended for a service or supply. Some technologies with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Please call or fax medical management to communicate the prior authorization request to us. The address, phone numbers, and fax numbers are listed in Chapter 1 Contact and Administrative Information. This is not an all-inclusive list. The most complete, up-to-date list of services for which prior authorization is recommended can be found at MedicareBlue PPO Medical Prior Authorization Request Forms are available at in the Provider and then Forms section. Services for which prior authorization is recommended Bariatric surgery Home health (PA must be initiated by the Home Health Care Agency) Home infusion Skilled nursing facility admissions Transplants o Organ except cornea and kidney o Bone marrow/stem cell Deep brain stimulation October

6 Drugs, including but not limited to: o Growth hormone o Intravenous immune globulin (IVIG) Reconstructive procedures and potentially cosmetic procedures such as: o Blephoroplasty o Rhinoplasty o Panniculectomy o Scar excision/revision o Reduction mammoplasty, mastopexy Durable medical equipment exceeding $1,000 Prosthetics exceeding $5,000 Vagus nerve stimulation Surgical treatment of sleep apnea Types of Prior Authorization Prior authorization procedures and forms may vary depending on the type of service, device, or drug. Prior authorizations are detailed and separated into the following categories: Home health Home infusion Medical policy Skilled nursing facility admissions Specialty pharmacy Transplant Durable Medical Equipment (DME) Prior Authorization The DME provider can provide all details required, such as specific features, costs, alternatives and documentation of medical necessity as provided by the physician as needed. MedicareBlue PPO Durable Medical Equipment and Medical Supply Prior Authorization Request Forms are available at in the Provider and then Forms section. HCPCS E1399 Note that HCPCS code E1399 should be used only when there is no other HCPCS code to describe the equipment, such as custom-made equipment. Incomplete information or incorrect use of HCPCS codes may result in delayed review or incorrect claim payment. MedicareBlue PPO reserves the right to return to the provider any prior authorization request or to reject a claim that is submitted with an E1399 October

7 HCPCS code without a complete description of the equipment. We will accept all valid HCPCS codes and will reimburse as appropriate. Eligible or Non-covered DME Equipment which is primarily and customarily used for a non-medical purpose may not be considered medical equipment for which payment can be made. Equipment primarily for independence, selfsufficiency and prevention or reoccurrence of medical conditions, are not generally considered as treatment of existing disease. Examples of ineligible DME include: environmental aides, exercise equipment, safety equipment, home modifications, sensory aides, vehicle modifications and transportation aides. Prescription or Doctor s Order It is not necessary to submit a copy of the prescription or doctor s order for DME. It is sufficient to maintain this information within the patient s medical record at the supply company or ordering physician s office. DME Waiver Requirement Participating DME suppliers must obtain a signed, written waiver from the member that describes financial responsibility for non-covered (upgraded or deluxe) items. Refer to the MedicareBlue PPO Durable Medical Equipment Upgrade form available at in the Provider and then Forms section. The waiver must also state the following: Piece of equipment that would have been covered under Medicare guidelines Member is aware and agrees that MedicareBlue PPO will only pay for the item that would have been covered by Medicare (less any applicable cost sharing) Member will be responsible for the deluxe or upgrade charge in addition to the cost sharing amount due on the Medicare-covered item This waiver must be kept on file at your office. Do not send it to your local Blue Cross and Blue Shield plan. We do, however, reserve the right to see it. DME Upgrade Claims Submissions Two lines of service must be billed. The first line will include the DME HCPCS code and the standard charge for the equipment. The second line must include the same DME HCPCS code with the GA modifier (waiver of liability statement on file) and the upgrade or deluxe charge. For example: October

8 E0202 $550 (standard charge that will be subject to standard allowance reductions) E0202-GA $150 (deluxe/upgrade charge that will be denied as member liability) The GA modifier must be submitted as the first modifier on the second service line. Other applicable modifiers, such as NU (Purchase), should be submitted on the first service line. Case Management Overview Licensed health care professionals (registered nurses) provide telephonic case management services. These case managers coordinate health care services and manage benefits with members and providers. Case managers work with members who are facing chronic, complex, and/or catastrophic injuries, illnesses or diseases. They advocate for members with medical and behavioral health conditions that require a variety of different specialists and ongoing or intermittent care. The case manager coordinates services needed for home health, DME, outpatient therapy and skilled nursing facilities. They coordinate these services in order to maximize contract benefits, improve the patients health and ability to function, and reduce the likelihood of complications. The case manager facilitates appropriate access to a variety of specialized health care providers, and cases are often ongoing due to the nature of these chronic conditions. Case management ensures the coordination of benefits and health services across the continuum of care for members with a variety of health care needs. The goals of case management are to: Support and encourage individual accountability for health and wellness (self-care management) Promote the appropriate utilization of health care services Improve member satisfaction with the health plan and health care system Maximize health and functional outcomes Help members coordinate their needs and navigate services in the health care system Contact numbers are listed in Chapter 1 Contact and Administrative Information. Available Services Please contact case management when you have a patient who needs any of the following services: Home health care October

9 Skilled nursing or extended care facility admissions (SNF) Assistance with complex medical needs We have a case management brochure designed to educate members. This brochure is available for you to have on hand for your patients. If you are interested, please contact Medical Management for a supply. For the contact number, see Chapter 1 Contact and Administrative Information. Home Health Care Prior Authorization During the prior authorization process, our case managers assure that home health care services are reasonable and necessary for the treatment of the individual s illness or injury. Services must be ordered in writing by a physician and performed by a Medicare-certified home health agency. Home health care must be skilled rather than non-skilled or custodial and of such a level of complexity and intensity that the services can only be performed by a Medicare-certified home health agency. Our review is performed referencing Medicare criteria. Information requested from the provider over the phone or by fax: Caller s name and phone number Patient s name, MedicareBlue PPO member ID number and group number Home health agency name, phone number and contracting provider ID number Diagnosis Physician s name recommending the home health care Treatment request Homebound status Patient s support system (available caregivers) Medical history (onset of conditions, test results, surgeries, complications, previous treatment and response) Problems and functional limitations (measurements, baseline) Goals (objective, measurable, functional, time-specific) Plan of care Home program (physical, occupational and speech therapies) Re-evaluation (response and alterations in plan) Skilled Nursing or Extended Care Facility Admission Prior Authorization During the prior authorization process, our case managers review extended care (i.e., skilled nursing facility, nursing home, extended care unit, or swing bed) for both the appropriateness of the admission and continued length of stay. Our review is performed referencing Medicare criteria. Extended care must October

10 be ordered in writing from a physician and performed by a Medicare-certified facility. In order to be eligible for coverage, services must be skilled and provided on a daily basis. Custodial care is not a covered service. Information requested from the provider over the phone or by fax includes: Caller s name and phone number Patient s name, ID number and group number, if found on the member ID card Skilled nursing facility name, phone number and contracting provider ID number Diagnosis Physician s name who is recommending skilled nursing care Medical history (onset of condition; complications, problems and functional limitations; previous treatment response; recent hospitalizations or surgeries; support system) Plan of care Anticipated length of stay (Is the goal to return home, or is this a permanent placement?) Therapies being provided, if applicable (Will the claim be submitted using the extended care or the rehabilitation agency s provider number?) Name and number of contact person for concurrent review updates Hospice Care Hospice care for MedicareBlue PPO members is covered by Original Medicare. Claims for hospice care should be submitted to Original Medicare, not to your local plan. Any covered medical services that the patient may need unrelated to the hospice care are still covered by MedicareBlue PPO. Providers are asked to notify Provider Service when a member has elected hospice services, so that benefits may be managed appropriately. See Chapter 1 Contact and Administrative Information. Referrals to Case Management Members who are experiencing complex, chronic and/or catastrophic illnesses are referred to the Case Management Program through a variety of triggers. Potential case management recipients may be identified through internal and external referrals including the member s physician. A referral can be made by contacting Provider Service. See Chapter 1 Contact and Administrative Information. All referrals are screened and/or assessed by medical management staff to identify opportunities for case management intervention. October

11 Admission Notification, Plan of Care Review, Continued Stay Notification As part of your participating provider agreement, admission notification, plan of care review, or continued stay notification is recommended for inpatient admissions. Information Needed for Admission Notification The following information is necessary for inpatient admissions: Member identification and group numbers Member name and address Patient name, birth date and sex Admitting physician s name and individual provider number Admitting diagnosis code ICD-9-CM surgical procedure code and narrative, if applicable Date of surgery, if applicable Date of admission We recommend that you contact Provider Service to verify coverage, benefits and contract eligibility. See Chapter 1 Contact and Administrative Information. Discharge Date Notification / Length of Stay Review To meet the ongoing care needs of our members, we ask the admitting facility for discharge date notification. This information allows us to identify members who may benefit from additional medical management programs. For members who have an inpatient stay that exceeds seven days, a plan of care will be requested. Medical Management staff will contact the admitting physician s office or the facility to obtain clinical information, and to collaborate with discharge planners and social workers when high risk patients are identified. Hospital staff are encouraged to contact Medical Management to initiate case management services. Discharge Call Process MedicareBlue PPO s discharge follow-up is intended to be member-centric. Medical Management staff utilize inpatient discharge data to reach out to members identified as being at risk for re-hospitalization as well as collaborating with the member on other health care needs. Our goal is to help members successfully self-manage their recovery and promptly seek additional medical attention when needed. Following the member s hospital stay, a Medical Management clinician may engage the identified member in a telephone dialogue to support the member in the transition from hospital to home. Eligible October

12 members with longer hospital stays, complex needs, or long-term or chronic conditions are referred to case management. Purpose: Support the physician s discharge plan and the ongoing treatment plan Assess the member s understanding of their diagnosis, discharge plan, medication regimen and plan for physician or other clinical follow-up Educate, coach, advocate and empower members to achieve a positive health outcome Identify members at high risk for another acute episode and refer to appropriate resources Identify opportunities for integration with other MedicareBlue PPO programs, i.e., nurse triage phone line and heart failure program Chronic Care Management Heart Failure Program MedicareBlue PPO offers phone support for members with heart failure. The Heart Failure Program is based on the ACC/AHA 2005 Guideline for the Diagnosis and Management of Chronic Heart Failure in the Adult. Members are identified for this program by their providers, through health risk assessments and claims data analysis. The program s goal is to assist members to manage their chronic condition through education. Trained clinicians will: Talk with members about their condition Review their medications and current treatment Discuss best strategies, set goals and create an action plan Help members understand their physician s recommendations and support the plan of care Connect members to other helpful programs and resources, as needed Answer questions or address concerns Providers will receive written notification when their patients accept participation in the Heart Failure Program. Providers are invited to contact Medical Management while their patients are participating in the Heart Failure Program with questions or to direct patient education priorities. Referrals to the Heart Failure Program Members who are diagnosed with heart failure according to the ACC/AHA 2005 Guidelines are referred to Medical Management to be screened and/or assessed by a clinician for the opportunity to enter the October

13 Heart Failure Program. Case Management services coincide with the education and management of a member s heart failure. Participation in the Heart Failure Program is voluntary and available at no extra charge to the member. You may refer MedicareBlue PPO members to the Heart Failure Program by contacting Medical Management at Quality Improvement This section details information about the MedicareBlue PPO Quality Improvement (QI) program. The material explains what is expected from participating providers regarding their quality programs and defines provider requirements including medical record keeping practices. The information provided in this chapter is intended for all MedicareBlue PPO providers, however; some requirements may not apply in every facility. Basic Elements of a QI Program The Regional QI Department and Quality Improvement Committee will initiate clinical, service and safety activities based on the health plans performance data, such as: HEDIS and clinical indicators Clinical practice guideline monitoring Disease management conditions Quality of care reviews Continuity and coordination of care Accessibility and availability reports Enrollee satisfaction surveys Telephone responsiveness Grievances and appeals Timeliness of handling medical and pharmacy management requests Activities as determined by CMS MedicareBlue PPO subscribes to the philosophy of Quality Improvement and the multifaceted benefits it offers. A successful program has three basic elements: it must be customer-focused, data-driven and process-outcome-oriented. MedicareBlue PPO uses the Plan-Do-Study-Act (PDSA) model and a series of PDSA cycles to identify and implement QI strategies and activities. October

14 Plan: Do: Study: Act: Evaluate data, identify opportunities to prevent/improve health problems or occurrences, and identify appropriate intervention strategies based on best practices and known barriers. Implement program(s) to address identified needs and barriers. Measure the effects of the improvement and assess its effectiveness. Continue intervention if effective. Adjust as necessary to achieve goal targets. Repeat cycle if intervention doesn t achieve desired result. Issues selected for special studies or ongoing monitoring reflect the population served, enrollee satisfaction data, high volume procedures and conditions, high risk procedures and conditions, and areas that may be amenable to actions for improvement that will result in system-wide improvements in the health care delivery system. The Regional QI Committee needs your cooperation and participation through your local plan s QI program. Collaboration with MedicareBlue PPO Program A collaborative effort is needed to mutually service our members with excellent care and services and to fulfill CMS requirements to collect and report HEDIS data, conduct quality improvement projects and to improve process and outcome measures. Leadership within an organization must support and embrace the philosophy of quality improvement for it to succeed. Advising, supporting and actively participating in the development and implementation of good process improvement is vital in providing excellent care and services. MedicareBlue PPO has established standards and policy requirements for practice sites to follow in pursuit of excellent care and service. Accessibility Requirements Providers will not discriminate against any MedicareBlue PPO member in the delivery of health care consistent with the benefits covered in their policy based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment. Providers shall follow the evidence-based clinical practice guidelines for preventive health screening and selected health conditions adopted by MedicareBlue PPO. October

15 Providers shall adopt and utilize patient safety practices that ensure the prevention of harm to our members and shall cooperate with the regional quality improvement program to investigate and address concerns about services which may result in serious adverse outcome to MedicareBlue PPO members. Providers shall provide or arrange for the provision of medical advice to members on a timely basis, and be available 24 hours per day, 7 days per week via a telephone response. A provider shall not be obligated to provide any type or kind of health service that he or she does not normally provide for others or that for which the provider is not authorized by law to provide. Timeliness requirements within which a member can obtain services: Category Preventive care appointment Routine appointment Urgent appointment Emergent After-Hour Telephone responsiveness Standard Within 8 weeks of request Within 14 days of request Within 48 hours of request Immediate 24 hrs, 7 days week During office hours, enrollees calling a provider will be assessed according to patient care needs by a physician or designee. A timely response to incoming phone calls: Calls answered in six rings or less On hold two minutes or less Medical Record Keeping Policies The patient medical record is a vehicle for documenting services provided and evaluating continuity and coordination of care. It also serves as legal protection for the patient and practitioner. MedicareBlue PPO requires medical records to be maintained in a manner that is current, detailed and organized. Minimum Requirements Medical records are kept in a secure location. Providers must have a tracking process in place for ease of retrieval All pages must have either patient name or ID All entries are dated, legible, and signed Problem lists are present and up-to-date Allergies/adverse reactions/nka prominently displayed October

16 Current medications and dosage prominently noted Recommended immunizations and preventive health care documented Consultation report and labs/radiology results are initialed and dated by primary care provider to acknowledge review Statement as to whether an Advance Directive was executed Presenting complaints, diagnoses, and treatment plan Past medical history, physical examinations, necessary treatments, and possible risk factors for the member relevant to the particular treatment Written Policies Each provider will have policies and procedures in place for the following topics that apply to the services provided in the facility. Policy Required Recommended Risk Management Elements Advance Directives Information made available Discussion is documented in medical record Copies retained Hospitals notified upon admission MedicareBlue PPO contracted physicians and providers must document in a prominent place in medical record if individual has executed Advance Directive [ (b)(1)(ii)(E)] Communicable Disease Reporting Requirement to report communicable diseases by State Health Department Reporting timeframe (within one day) Responsibility of reporting defined Forms, completion and submittal addressed Confidentiality and Security of Medical Confidentiality of health information and medical records that meets state and federal requirements, including release of information Records Review of the confidentiality policy and procedure is performed at least annually with staff Ensure timely access for/to enrollees to the records and information that pertains to them Foreign Language Assistance provided for both situations Translation and Interpreter available for phone calls and face-to-face interactions Hearing Impaired Enrollee/family are notified that interpreter is provided Services Resources are identified October

17 Policy Required Recommended Risk Management Elements Medical Emergency Mechanism in place for responding Medical emergency code is identified Identify who directs activities Identify who determines if 911 is called Medication Management Mechanism in place for procuring, storing, controlling and distributing medications Narcotics addressed, even if to say they are not kept at the facility Recalls addressed Emergency and sample drugs addressed Sign-out log covered Prescription pad accessibility addressed Communication Communication between primary care and medical specialists and primary care and behavioral health specialists is critical to safe, effective care. Practitioners must develop and implement appropriate communication processes to ensure coordination of care. October