A 435-page tool box of resource utilization management (UM) model policies, procedures and plans that ‘work’ for traditional, streamlined, open access and other cost-effective management strategies. Contact capitation and other variations of traditional capitation compensation strategies are detailed including those for emergency services. Includes numerous forms, audit tools, benchmarks and job descriptions. References and resources are included as well. This product is updated for 2007.

Table of Contents

Capitation Toolbox –Introduction; Behavioral Health Services; Capitation fundamentals; Direct access to specialty care (self-referral); Capitation Pros and Cons; Medical Loss Ratios; DRG payment systems; HMO Pools; Readiness Audit List; Levels of risk in capitation; Adverse selection; Medical group/IPA responsibility; Sponsor Discounts; Contracting Issues; The capitation contract; Physician and other ambulatory visits per year (average); Hospital Admission Rates and LOS – All Payer; Capitated HMO contract, Representative major financial pools

Capitation expense allocations; Risk sharing arrangements (table); Flow of funds, algorithm – representational example; Capitation payment date issue in relation member enrollment; Hospital per diem rates/discharge timing considerations; Physician Encounter benchmarks; Critical success factors for managed care organizations, checklist; Capitation rate example; Health Plan Operational Metrics; Physician Encounter benchmarks; Specialty Physician Payment Systems; ‘Per Case’ or global package pricing strategies; Contact capitation; Specialist capitation; example strategy/plan; Pay for Performance (P4P) programs; Ancillary provider contracts; Medicare ‘Fraud and Abuse’ /Health care compliance

Utilization/Resource Management Toolbox – Introduction to Utilization Management; Guidelines; Effect of guidelines on care; Medical necessity – What is it?; Case Law Citations – related to medical necessity; Length of Stay Guidelines/DNR orders; Unplanned readmissions w/audit form

Utilization/Resource Management Program: Program elements; Referrals within the medical group; Medical necessity; Outreach; Communication concerning UM policies to patients and the public – example; Program elements; Report requirements; Pharmacy Management; Documentation requirements; Utilization Resource Management Department; Discharge delays

Basic elements of an UM plan (refer to UM Plan model in addendum); Consultations vs. referrals; UM Department staff and staffing; UM Committee; UM Policy and Procedures – example for medical group/IPA/MSO; The Review Process; Assignment of Case Numbers P&P

Benefit and eligibility determinations – Identification card; Financial Responsibility Guarantee Form; Eligibility and Benefits Verification – P & P; Precertification/Certification Worksheet; Eligibility FAQs

Case or Care Management (CM) - Introduction; CM program savings; Hospital UR/Case Management – functions; CM roles and responsibilities; Primary Case Manager – Role/Responsibilities; Hospital Case Manager – Role/Responsibilities; Specialty Case Manager – Role/Responsibilities; Specialty Case Management; P & P; Specific disease examples for case management services; Criteria for Social Service/Counseling Management; SCM case closing; P & P; SCM discharge form example; Hospital Case Manager UM Variance Reports, example list; Preadmission Review/Precertification or ‘Precerts’; Hospital charges for non-covered services; Preadmission case management screening tool;

Procedure for prospective review; Prior authorization check list form; Diagnostic referrals; Diagnostic radiology referral form; Procedures for ‘Patient Care Plan’ form completion prior to review; Authorization Request Form; Request for Authorization - additional mental health services; form; Request for Authorization to provide additional services; form; Physical Therapy note; Request for continuation of services; form; Referral Authorization form; Review Worksheet form; Reviewer Communication Form to Requesting Provider

Observation status for acute care - P & P

Review Process – Role of the physician advisor, Concurrent and Retrospective; Concurrent review; policy & procedure; Concurrent review, work sheet form; Concurrent review check list form; Authorization review work sheet form; Length of Stay and next review date assignment; ‘stickey’ example; Specialty pre-admission authorization; Blended Specialist-Primary Care Physician for a Qualifying Patient; Primary physician notification; P&P with form

Retrospective review, policy; Inappropriate admission - change in status; Discharge planning; policy and procedure; Authorization of special services; Periodic review of pre-authorization policies – example; Specialty pre-admission authorization; Primary physician notification; P & P with form; Authorization approval notification form; Authorization denial notification form; Outpatient surgical authorizations; procedure; Complications following non-covered services, policy; Custodial care, definition; Audit for Access Time to Specialty Care Following Primary Care Referral

Ambulatory Services Management - The Minnesota Medical Practice Model; Outpatient surgical authorizations, procedure; Podiatry Services

Referral Authorization Strategies – ‘Passthroughs’ or ‘Automatic’ Approval or ‘Direct Access’ – example list; Streamline referral process; ‘Open Access’ plus example P & P for Chemical Dependency; Delegation of UR function to selected physicians; Specialty physician delegated procedure list, by specialty; Urology referral check list; Orthopedic referral checklist;

Emergency Services; P & P; Alternative care or redirection of care; References and resources related to ER services; ‘Out of Area’ Care; P & P; Procedure for ‘out of Network’ Arrangements for care; Letter/Contract to ‘Out of Network’ provider; Payments for Emergency Services to Non-contracted Providers – California Law

Home Health Care; Home Health/Hospice Case Management, Policies/procedures; JCAHO Emergency Preparedness for Home Care; Home Health/Hospice - Case Management; Homebound criteria; Common reasons for failure/lack of use of home health services, Skilled Home Nursing Care; Home Nursing for Ventilator or C-PAP Patients

Physician directed homebound program, Home visits by physicians following hospital discharge; Care Plan Oversight; Home health care referrals, P & P, Termination of home health care services, Home Health Aides/Assistants; Caregivers; Home health infusion services, Oxygen coverage guidelines, Home Safety Visit Checklist, Hospice; Eligibility Requirements; Hospice benefits; Hospice care in a SNF; Karnofaky Performance Scale; Home Health Care for Psychiatric Services

Skilled care Services; Skilled Nursing Facility, payment issues; Levels of skilled care;

Durable Medical Equipment; P & P; DME form;

Denials, Appeals, Redeterminations, Grievances – Introduction; Insurance denials for alcohol-related emergency treatment; Denial and Appeal Process, policies and procedures; Medicare plus Choice and Medicare time frames for appeals; Work sheet for physician reviewer; Standard denial letters; Denial Letter to provider, example format; Denial Letter; commercial member format, examples; Denial Letter; Medicare HMO member format; Denial letter, SNF benefits; Denial retraction letter format; Denial letter, exhaustion of SNF benefit, commercial; Acknowledgment of receipt of notice, SNF benefits denial; Notice of non-coverage; fax sheet example; Appeals process, policy and procedures; Appeals Committee; Complaints/grievance reporting vis a vis provider contracts; Appeals Review Status Tracking Form; Grievance tracking; References & resources re: appeals, denials, grievances; Denial rate – examples; Claims letter denying payment, non-covered services, to com. Member; Claims letter denying payment for non-covered services, to provider; External Reviews;

Discharge Planning - Discharge Planning; Policy & Procedure; Stratis Health (MN QIO) Discharge Planning Quality Resources Kit (links); Notes

Annual U/RM Work Plan – Special Studies; Program Surveys; Radiology performance profile for medical groups; Tracking Hospital and SNF Admissions; Statistical reports, hospital bed days and other benchmarks

Algorithms – Prospective and concurrent review; Preadmission evaluation; Electronic referral process; Ambulatory Care Referral process; Alternative UM process; Automatic or pass-through procedures; External provider authorization process; Preadmission ER Evaluation; Utilization/Case Management, Behavioral Health; UM Case Management; Med/Surg, OB & ICU; Ambulatory Care Authorization process

Integrated Quality Management/Improvement Strategies – Building a foundation for Quality constructs; Where should a higher-risk procedure be performed in a specific patient or population of patients?; Introduction to the QA/QM/QI Department; Integration of Utilization/Quality Management Programs; QM/UM overlap examples; ‘Pay for Performance’ programs; QI/QM Clinical Indicators/Performance Goals Standards list; Case Mix Adjustment for provider profiles; Hospital/SNF QA Screens; Provider Sanctions and Fines: QI Committee; Fine Notification Form; QM staffing ratios

Administrative/’Back Office’ Strategies, Policies and Procedures – Staffing ratios for a MSO; Case contracting Claims processing; Submission of encounter data and claims; Coordination of Benefits; Third party liability; IBNR;

Operational standards (List); Committees; New Technology Assessment, P & P; Medical Records – Issues in managed care contracts; Non-contracted or ‘Out of Network’ Claims;

Hospital care performance standards, Hospitalist/attending physicians; Physician management services, conference time/phone calls; Primary physician selection; Sign Language Interpreter services; Sanctions and Fines – Utilization Management, P & P; UM Committee Meeting Attendance Requirements; Social Work Services; Quarterly Primary Physician Dinner Meeting Attendance Requirement;

Balance sheet & Income Statement Ratios; Transitional Care Center policy; Transportation, medical; UR Organizations, fiduciary responsibilities; Waiver of Co-payments – P & P; Worker’s Compensation; ERISA

Education Strategies – Education for Patients and Providers – Why???; Emergency care brochure; Authorization process brochure; Speed up the authorization process by ...; The Big Secret; Hospitalist care – explanatory brochure

R/UM Staff Job Descriptions and Effectiveness Evaluations – Medical Director or Chief Medical Officer; UM Physician Advisors/Directors job descriptions; Clinical Director, UM; Managed Care Coordinator; UM; Coordinator (Nurse reviewer); Concurrent review nurse coordinator; Care Coordinator/Case Manager; Managed Care Technician I and II; Pharmacy Benefit Manager;

UM Staff Training and job standards; UM Reviewer Evaluation, P & P; Assessment tool for UM staff; Utilization review, Inter-rater Reliability Evaluation P & P; Audit Tool; Audit of UM Authorization and Denial Services with tools and forms; Audit - hospital 1 to 2 day admission tool

References and resources – an extensive section, alpha listed by topic

Appendices – Utilization Management Program model; UM financial data collection - example formats; Medical Policy/Medical Management Committee; Inpatient Days Prior to a Surgical Procedure – Policy; Payment denials for surgical errors; Surgical Length of Stay ‘Benchmarks’ or Targets; Medical LOS examples – refer to the following LOS by DRG table; Managed Care Legal Resources on the Web; Medicare plus Choice, synopsis of medical management rules and regulations; Demographic cost factors, senior, by class; Key Contacts at CMS; Hospital care ‘length of stay’ targets, by age range; Frequency by Diagnostic/Procedural Group, Acute Hospital Care, California HMO data; Hospital Days, Physician Encounters and Ambulatory Visits; LOS targets by DRG; Claims management consultants - resources