Subject: Utilization Management Program Author: Candis Kliewer, RN
Department: Utilization Management Product: Commercial, Senior
Revised by: Linda McKevitt, RN
Effective Date January 1997 Revision Date 1/21/15 Pages 10 Approved by: ____________________________________ Date: 1/15/2014
PURPOSE AND SCOPE:
The purpose of the Utilization Management Program is to ensure the delivery of medically necessary, optimally achievable, quality patient care through appropriate utilization of resources in a cost effective and timely manner to all members. To ensure this level is achieved and/or surpassed, programs are consistently and systematically monitored and evaluated. The evaluation process is fully documented and when opportunities for improvement are noted, recommendations are provided. The program description includes the scope of the program and the process and information sources used to make determinations of benefit coverage and medical appropriateness. This program will ensure that:
A. Services will be provided by Riverside Physician Network contracted providers or health plan (e.g., hospital network) contracted providers unless authorized by the Utilization Management Committee or Medical Director.
B. Hospital admissions and length of stay are authorized on the basis of medical appropriateness and appropriate place of care.
C. Appropriate care is offered in a timely manner and is quality-oriented. D. Costs of services are monitored and evaluated.
E. Riverside Physician Network will maintain compliance with the regulations set for the specific contracted member populations (e.g., Commercial, Medicare). F. Riverside Physician Network considers the needs of the individual such as: age,
co-morbidities, complications, progress of treatment, psychosocial situation, and home environment when applying criteria.
G. California licensed physicians, licensed nurses, and unlicensed staff carry out the responsibilities designated for their level of expertise. Qualified health
professionals assess the clinical information, which is utilized in making utilization management decisions. Appropriately licensed health professionals supervise all review decisions.
H. Providers are not restricted from advocating on behalf of the member, or advising a member regarding care.
GOALS AND OBJECTIVES:
A. To provide ongoing monitoring/evaluation activities which address and correct over/underutilization and inefficient coordination of medical resources.
C. To ensure that governmental and other regulatory agency guidelines, standards and criteria are adhered to when applicable.
D. To ensure that services rendered are within the guidelines of and are authorized by the member’s health plan benefits and delivered by contracted, credentialed providers/practitioners.
E. To respond to member and provider/practitioner complaints/appeals after
coordinating comprehensive and timely investigations associated with utilization issues.
F. To perform peer review in conjunction with the Quality Management Program when it is necessary.
G. To ensure that approved services are timely, medically necessary and consistent with the diagnosis and required level of care.
H. To facilitate communication and develop positive relationships between members, practitioners, and health plans by providing education related to appropriate utilization.
I. To ensure that members with complex health needs are identified for the Ambulatory and Special Needs Case Management Programs to facilitate their access to the most efficient resources for preventing hospitalizations through proactive planning and prevention, and providing a treatment continuum. J. To ensure the development and implementation of effective health
education/promotion programs in order to reduce overall healthcare expenditures. Health education programs which are in compliance with all applicable
regulations will be available to the members. Provider and member education will be offered, evaluated and improved on a continual basis.
K. To implement procedures to prevent the re-occurrence of problematic utilization issues.
L. Review criteria based on reasonable medical evidence will be used to make decisions pertaining to the utilization of services. Riverside Physician Network utilizes current (no more than two years old or most current editions published) standard criteria and informational resources to determine the appropriateness of healthcare services to be delivered (e.g., Apollo, Milliman Care Guidelines, Health Plan criteria, Medicare). Riverside Physician Network involves appropriate practitioners in the development and approval of the criteria. All services authorized by the Utilization Management (UM) Staff will be evaluated to determine medical appropriateness based upon approved standard criteria. The criteria are evaluated, updated (as appropriate) and approved on at least an annual basis by the Utilization Management Committee. The criteria are available upon request to all participating providers, members, and the public. This can be arranged through the Utilization Management Department by contacting the UM Supervisor at (951) 788-9800. (See UM P&P, UM Criteria – Practitioners & Patients.)
M. A designated senior physician has substantial involvement in the implementation of the UM Program.
O. To evaluate and monitor healthcare services provided by Riverside Physician Network contracted/credentialed providers through tracking and trending data. P. Utilization Management data will be incorporated into the Credentials
Department’s process of re-credentialing providers.
POLICY:
Riverside Physician Network’s Utilization Program will assure:
A. A designated Behavioral Health Care Practitioner has substantial involvement in the implementation of the UM program which can include setting policy, reviewing cases, participating in the UM Committee, and development and adoption of Behavioral Health care standardizing criteria. The designated Behavioral Health Care Practitioner is a member of the UM Committee and participates in behavioral health care aspects of the program such as review of bed day and readmission rates. Behavioral Health referrals are processed according to the member’s health plan benefits.
B. Riverside Physician Network ensures a Utilization Review physician is available by telephone to discuss determinations based on medical appropriateness.
C. A mechanism is present for checking the accuracy and consistency of application of the criteria by physicians and non-physicians. An evaluation of the utilization review decision-making process is conducted on at least an annual basis.
D. Criteria used in the determination of medical appropriateness of services will be clearly documented. This information will be available, upon request, to participating providers. E. Documentation for case review and authorization/denial of services demonstrates efforts
are made to obtain all necessary information, including pertinent clinical information. 1. Relevant clinical information is obtained when making a determination of
coverage based on medical appropriatenessand benefit coverage for inpatient and outpatient services. The treating physician is consulted as appropriate.
2. Information that is collected to support the UM decision-making is documented. This documentation shows that relevant clinical information is gathered
consistently to support the UM decision-making process.
3. For Medicare Deeming, Riverside Physician Network will ensure it complies with national coverage decisions, general Medicare coverage guidelines and written coverage decisions of local Medicare contractors.
4. Patients’ legal representatives will be allowed to facilitate care or treatment decisions when they are unable to do so.
F. Board certified physician consultants from appropriate specialty areas assist in making medical appropriate determinations.
G. A licensed physician (Medical Director or physician designee) reviews all denials, which are based on medical appropriateness and procedures will be followed in accordance with the Denial Review policy.
H. Determinations are made in a timely manner. The urgency of the situation always is considered to ensure that the request is processed appropriately and according to approved time frames.
1. Riverside Physician Network approved standards for timeliness of utilization management decision-making are implemented (see ICE and CMS timeliness standards in the Referral/Authorization Process policy and procedure).
3. If the standards are not met, Riverside Physician Network will take action to improve performance.
I. Member and Provider grievances will be forwarded to the health plan within 24 hours or the next business day of our receipt. Riverside Physician Network is not delegated to investigate grievances. Information and responses requested from the health plan regarding these grievances will be coordinated from the provider(s) and submitted back to the health plan in a timely manner.
J. There are documented mechanisms to evaluate the effects of the UM program and process using member and provider satisfaction data, staff interviews and/or other appropriate methods.
1. Information is gathered at least every year from members and providers regarding their satisfaction with the UM process.
2. Identified sources of dissatisfaction are addressed.
K. Utilization tracking and trending data will be submitted on a regular basis to the Utilization Management (UM) Committee. The data will be analyzed by the UM Committee to determine outcomes related to over utilization or under utilization of services. Opportunities for improvement will be identified and the Committee will decide which opportunities to pursue. The Committee will make recommendations for necessary intervention based on the findings. After intervention strategies have been implemented, re-evaluation will be done, and the results will be reviewed by the UM Committee.
L. Quality-related issues will be referred to the Quality Management (QM) Committee. The UM and QM Committees will work together to resolve any cross-related issues or
problems.
M. The UM Program will include continuous quality improvement processes which will be coordinated with quality management activities as appropriate. The role of the UM Program in the Quality Management Program will be described.
N. The Utilization Management Program will include the effective processing of
prospective, concurrent, on-going ambulatory and retrospective review determinations by qualified medical professionals. The areas of review will include:
Inpatient hospitalizations
Outpatient surgeries
Selected outpatient services
Rehabilitative services
Selected ancillary services
Home healthcare services
Selected pharmaceutical services
Selected physician office services
Out-of-network services
O. Provider and member appeals will be handled efficiently according to medical group policy and procedure (which includes compliance with regulatory time frames). P. A viable case management program will exist which clinically and administratively
identifies, coordinates, and evaluates the services delivered to those members which require close management of their care.
Q. The Utilization Management Committee will meet on a regularly scheduled basis and not less than quarterly.
S. The approved annual Utilization Management Plan will be submitted to the contracted health plans. Other Utilization Management reports will be submitted to the health plans according to contractual agreements.
T. Contracted health plan surveys which are conducted annually will involve the cooperation of the Riverside Physician Network staff.
ORGANIZATIONAL STRUCTURE AND RESPONSIBILITIES OF OVERSIGHT COMMITTEE RESPONSIBILITIES/FUNCTIONS:
The organizational chart accurately reflects the Utilization Management Staff and Committee reporting structures. Staff positions and Committee descriptions explain all associated responsibilities and duties. The staff ratios are equivalent to the organization’s needs and are accommodated by the Utilization Management Program’s budget.
Reporting relationships are clearly defined. Performance objectives are included in the staff evaluations. Interdepartmental coordination of managed care utilization of services is clearly delineated in the description of each department.
A. Board of Directors
Responsibilities include the development and maintenance of the Utilization Management (UM) Program. The responsibility for creating and
implementing the UM Program’s infrastructure is delegated to the Utilization Management Committee.
The Board of Directors oversees all Utilization Management Program
activities, therefore, the UM Committee reports to the Board of Directors on at least a quarterly basis. Documented summaries of utilization statistics and focus study results are presented.
The Board of Directors may delegate additional responsibilities to the Utilization Management Committee as necessary.
B. President
Responsibilities include overseeing the organization and management of the Utilization Management Program with a focus on the program’s financial viability, the allocation of resources and staffing, and the interdepartmental effectiveness of the program.
C. Medical Director
The Medical Director has an unrestricted license to practice in the State of California with license verification accomplished at the time of renewal.
Responsibilities include implementation of the Utilization Management Program. The Medical Director serves on the Utilization Management Committee and is responsible for performing or designating Chairmanship of the Committee. Also, he/she works with the Utilization Management
Committee and health plans, when applicable, in determining the appropriate utilization of services.
Authorizes specific hospital, SNF, Home Health, Tertiary Referrals, as well as emergency service requests.
Denies services requested if medical appropriateness requirements are not met.
D. Director of Clinical Operations
The Director of Clinical Operations is a RN/LVN with current licensure in the State of California. Responsibilities include the operational execution of the Utilization Management Program under the direction of the President and Medical Director. The Director of Clinical Operations is responsible for managing the UM Staff which may include the following positions:
Utilization Management Supervisor Utilization Review Nurse
Authorization Coordinators Inpatient Case Managers Inpatient Coordinators
Ambulatory Nurse Case Manager Utilization Administrative Support E. Staff
Utilization Management Supervisor: An RN/LVN with current licensure in the State of California. Responsible for direct supervision of the
Authorization Coordinators. Assists in monitoring and execution of the UM Program and Workplan.
Utilization Review Nurse: An RN /LVN with current licensure in the State of California. Responsibilities include overseeing the authorization process by processing precertification referral requests according to medical necessity guidelines and benefit coverage.
Authorization Coordinators: Responsibilities include data entry of authorizations requested, verifying benefits/co-pay and obtaining additional medical information as requested by physician reviewers/nurses. In addition, they would complete the approved authorization process; notify the provider of the outcome and input “automatic approval” authorizations as designated by approved list.
Ambulatory Nurse Case Manager: An RN/LVN with current licensure in the State of California. Responsibilities include reviewing the clinical aspects of inpatient and outpatient care to ensure the most efficient utilization of resources allocated to health service functions. Specific criteria and standards must be met for all levels of care. The Case Manager utilizes clinical
guidelines and team-based knowledge to address the needs of patients along the entire spectrum of care. They are integral to “disease management” and participate in the identification and follow-up of high-risk members.
Inpatient Coordinators: Responsibilities include receiving information from outlying hospitals and data entering the information received. Developing logs to track and trend patients’ out-of-area. Reporting of information to the Hospitalist, Case Managers and health plans. Tracking and reconciling of bed days with Hospitalist and health plans from data submitted.
Utilization Administrative Support: Responsibilities include direct report to the Medical Director. Duties include appropriate letters to providers, health plans and educational letters to members. This would also include
administrative support with new policies, revisions, Utilization Management Committee minutes and Corrective Action Plans.
F. Frequency and Schedule of Meetings
The UM Committee meets at least quarterly and may meet monthly or more frequently if deemed necessary by the Chairperson, the Medical Director (if different), the President, or the Board of Directors.
G. The Utilization Management Committee Processes and Activities
1. Responsibilities of the Committee and Subcommittees: The Utilization Management Committee will be established as a standing committee of Riverside Physician Network, which reports to the Board of Directors. The Chairperson of the UM Committee will be a physician and have current licensure by the State of California. The Chairperson will determine the beginning and end of meetings, will facilitate discussion, and ensure all policy and procedures are followed.
2. Responsibilities of the Medical Director: The Medical Director, Chairperson, or designee will review and sign the committee minutes and correspondence. The Medical Director will communicate as necessary appropriate issues to Committee members. The Medical Director will ensure that the Committee reports are forwarded to the Board of Directors, as required by the current policy and procedure.
3. Linkage with the following departments will occur: QM, Contracting, Provider Relations, Member Services, Claims, and IS as appropriate.
4. Term of Membership: The UM Committee members will serve one-year terms with the possibility of reappointment for two terms.
Director and a panel of up to five physicians. This would include PCP’s and Specialists. Specialists could consist of an Endocrinologist, OB-GYN, Urologist, Nephrologist and a Psychiatrist. Non-physician UM Committee members will be appointed by the Medical Director of Riverside Physician Network. These may include: the Director of Clinical Operations, the UM Supervisor, QM Nurse, Nurse Case Manager, Provider Relations
Representative and UM Administrative Support. Representatives including the CEO, Claims, Operations and Contracts may be asked to attend as guests. 6. Physician consultants from appropriate specialty areas of medicine and
surgery and/or additional specialty sources/organizations specified are available to review cases pertaining to their specialty.
7. During the period of time between UM Committee meetings, the Medical Director, or designee may function as an interim decision-maker to expedite the referral/authorization process.
8. Voting Rights: Only the physician members of the UM Committee have voting rights.
9. A quorum of 3 physicians must be present at each meeting.
10. Contracted Health Plans may send staff to attend meetings on a pre-approved basis. The health plan staff may attend the part of the meeting that covers members assigned to their health plan. The staff must sign a confidentiality statement prior to each meeting.
11. The Medical Director will manage urgent issues between meetings. In the case of disagreement between the referring physician and the Medical Director in the care of a patient, the case will be coordinated between the Chairperson of the UM Committee and/or QM Committee and the Medical Director.
12. Communications will be provided regarding any changes or new policies having direct impact on practitioners/providers.
13. Data collection will be used to monitor and evaluate care and service in relationship to specific aspects of each department as follows:
Provider/Member satisfaction surveys
Referral turn-around-time audit
UM Reviewer Inter-rater Reliability Surveys
14. Clinical Data Collection: Analysis of inpatient and outpatient data for tracking, trending and education purposes. This will be obtained through Hospitalist data, Claims and UM Reports and will be presented to the UM Committee monthly. Examples:
Bed Days/1000
ER Admits/1000
Adverse Outcome
Utilization Patterns for over and under Utilization
Referral Patterns
Retro Authorizations
Pharmacy Patterns
High Risk/High Volume Procedures/Diagnoses
outcomes is done through weekly staff meetings and memos.
16. Utilization Management members will sign a confidentiality statement annually
17. Problem Resolution:
Description of process for identifying, monitoring and evaluating clinical issues, utilizing performance goals.
Reports from ancillary departments linked to and impacting the UM Department will be reviewed and monitored.
Any UM problems identified by the QM Committee and referred will be addressed.
Corrective action when indicated to include intervention, measurement of effectiveness and correction as applicable.
Any actions or decisions will be documented in the UM Committee minutes.
18. The Utilization Management Program’s plan, policies and procedures will be reviewed and approved, and if necessary, revised on at least an annual basis, 19. The Utilization Management Annual Summary and Evaluation Report of
utilization activities will be annually submitted to the UM Committee and Governing Body and any requesting contracted health plan. Upon
member/practitioner request, a description of the Quality Management Program and report of the progress made in meeting goals will be provided. 20. Utilization Management Semi-Annual Reports will be reviewed and approved
on a semi-annual basis, submitted to the medical group’s Governing Body, and any requesting contracted health plan.
21. A Utilization Management Work plan is developed utilizing the most current approved Industry Collaborated Effort (ICE) forms and implemented each year by the Utilization Management Committee.
H. Utilization Management Committee Meeting Minutes Will:
Be documented contemporaneously, dated, signed by the Committee
Chairperson or Medical Director, will be current and available for contracted health plan review.
Indicate attendees.
De-identify members/practitioners/providers.
Include attachments of applicable reviewed items.
Be stored in a confidential area with authorized staff access only.
Reflect the Utilization Management process Committee decisions, action plan implementation and evaluation/follow-up.
Contain results/reports of clinical data/statistics and audits/studies/surveys.
Document Inpatient and Outpatient review findings.
Reflect review of practitioner UM statistics, Denials/Appeals.
Provide evidence feedback to, ongoing education of and communication with practitioners and/or members by Committee.
Contain Utilization Management information relevant to any Quality Management issue identified with reports to the Quality Management Committee and any applicable subcommittee(s).
Minutes will reflect continuity of issues from meeting to meeting, problem identification, action plan, follow-up and re-evaluation.
I. Policies and Procedures
The systematic process for conducting Utilization Management activities will be referenced in separate policies and procedures which will be revised as needed, and reviewed annually by the Utilization Review Committee. The Utilization Management department will disclose upon request (will be mailed) the utilization management policies, procedures, and criteria used to authorize, modify, or deny healthcare services to the public. [CA Health & Safety Code 1363.5(b)(5)]
J. Studies/Surveys/Audits
All Utilization Management Committee (UMC) audit/study/survey results (as well as audits from ancillary departments impacting UMC goals) will be presented to the UMC for analysis, determination of performance goals,
