Docstoc

TRICARE autism

Document Sample
TRICARE autism Powered By Docstoc
					Clinical Optimization
         Panel
Authorization and Referral




           Proprietary
Authorizations and Referrals
TRICARE West Region Health Leadership Conference                 February 26, 2009




• The UM Process Begins With Data Entry of All
  Requests For Care
      • TriWest meets/exceeds government standards
      • MaxMC logic assists in timely adjudication of
        referrals and authorizations
      • Ensures prompt identification of ROFR, urgent
        requests, and OHI
      • All requests are triaged to appropriate Hubs for
        processing




                                                   Proprietary
              Authorization/Referral Completions by Month
               TRICARE West Region Health Leadership Conference                                                                                                                                                                                                                                               February 26, 2009




                                                                                                                                                                                                                                                                                                                       Referral Totals
                                                                         Authorization/Referral Completions By Month                                                                                                                                                                                                   Auth Totals
                                                                                                                                                                                                                                                                                                                       Linear (Referral Totals)
              80,000

              75,000

              70,000

              65,000

              60,000
Completions




              55,000

              50,000

              45,000

              40,000

              35,000

              30,000

              25,000

              20,000
                                Jan-06
                                         Feb-06
                                                  Mar-06


                                                                    May-06
                                                                             Jun-06
                                                                                      Jul-06




                                                                                                                 Oct-06




                                                                                                                                            Jan-07
                                                                                                                                                     Feb-07
                                                                                                                                                              Mar-07


                                                                                                                                                                                May-07
                                                                                                                                                                                         Jun-07




                                                                                                                                                                                                                                                        Jan-08


                                                                                                                                                                                                                                                                          Mar-08


                                                                                                                                                                                                                                                                                            May-08
                                                                                                                                                                                                                                                                                                     Jun-08
                       Dec-05




                                                                                                                          Nov-06
                                                                                                                                   Dec-06




                                                                                                                                                                                                  Jul-07




                                                                                                                                                                                                                             Oct-07
                                                                                                                                                                                                                                      Nov-07
                                                                                                                                                                                                                                               Dec-07


                                                                                                                                                                                                                                                                 Feb-08




                                                                                                                                                                                                                                                                                                              Jul-08




                                                                                                                                                                                                                                                                                                                                         Oct-08
                                                                                                                                                                                                                                                                                                                                                  Nov-08
                                                                                                                                                                                                                                                                                                                                                           Dec-08
                                                                                                        Sep-06




                                                                                                                                                                                                                    Sep-07




                                                                                                                                                                                                                                                                                                                                Sep-08
                                                           Apr-06




                                                                                               Aug-06




                                                                                                                                                                       Apr-07




                                                                                                                                                                                                           Aug-07




                                                                                                                                                                                                                                                                                   Apr-08




                                                                                                                                                                                                                                                                                                                       Aug-08
                                                                                                                                                                                  Months




                                                                                                                                                          Proprietary
Authorization/Referral Completions Within 2 Days
TRICARE West Region Health Leadership Conference                                                                                                                                       February 26, 2009
                                                                                                                                                                               Referral 2 Day %
                                             Authorization/Referral Completions within 2 Days                                                                                  Auth 2 Day %


                102.00%



                100.00%



                98.00%



                96.00%
   Percentage




                94.00%



                92.00%



                90.00%



                88.00%



                86.00%
                                                     Jun-06




                                                                                                             Jun-07




                                                                                                                                                                   Jun-08
                                                              Aug-06




                                                                                                                      Aug-07




                                                                                                                                                                            Aug-08
                                                                       Oct-06




                                                                                                                               Oct-07




                                                                                                                                                                                     Oct-08
                          Dec-05

                                   Feb-06

                                            Apr-06




                                                                                Dec-06

                                                                                         Feb-07

                                                                                                  Apr-07




                                                                                                                                        Dec-07

                                                                                                                                                 Feb-08

                                                                                                                                                          Apr-08




                                                                                                                                                                                              Dec-08
                                                                                                           Months


                                                                                         Proprietary
     Referral Timeliness – Processed Within 3 Days
         TRICARE West Region Health Leadership Conference                                             February 26, 2009




                                                             Referral Timeliness
                                                                Processed within 3 Days
                           110%
% of Referrals Processed




                           100%

                           90%

                           80%

                           70%

                           60%

                           50%
                                  Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08
                                                                      Reporting Month




                                                               Proprietary
Authorization Timeliness – Processed Within 5 Days
TRICARE West Region Health Leadership Conference                                                                                                                             February 26, 2009




                                                                           Authorization Timeliness
                                                                                        Processed Within 5 Days
                                    110%




                                                                                          3%




                                                                                                       7%




                                                                                                                    6%




                                                                                                                                 9%




                                                                                                                                              8%




                                                                                                                                                           7%




                                                                                                                                                                        1%




                                                                                                                                                                                     7%




                                                                                                                                                                                                  7%
                                                                             3%
                                                   3%




                                                                2%
    % of Authorizations Processed




                                    100%




                                                                                        .7




                                                                                                     .7




                                                                                                                  .7




                                                                                                                               .8




                                                                                                                                            .8




                                                                                                                                                         .8




                                                                                                                                                                      .8




                                                                                                                                                                                   .8




                                                                                                                                                                                                .7
                                                                           .6
                                                 .4




                                                              .3




                                                                                      99




                                                                                                   99




                                                                                                                99




                                                                                                                             99




                                                                                                                                          99




                                                                                                                                                       99




                                                                                                                                                                    99




                                                                                                                                                                                 99




                                                                                                                                                                                              99
                                                                         99
                                               99




                                    90%                     99



                                    80%



                                    70%



                                    60%



                                    50%
                                           Jan-08       Feb-08       Mar-08       Apr-08       May-08       Jun-08       Jul-08       Aug-08       Sep-08       Oct-08       Nov-08       Dec-08
                                                                                                        Reporting Month




                                                                                                 Proprietary
ROFR and MTF Capability




          Proprietary
Right of First Refusal (ROFR)
TRICARE West Region Health Leadership Conference                 February 26, 2009




•      TriWest Reviews and Refines the ROFR
       Process to Ensure the Highest Level of
       Compliance Possible
•      Key Components Are
      •      Close monitoring of MTF Capability reports
      •      Daily ROFR audits by Clinical Liaison Nurses
      •      Monthly random audits of BSRs




                                                   Proprietary
Right of First Refusal (ROFR) Acceptance Rates
TRICARE West Region Health Leadership Conference                                                                       February 26, 2009




                                        West Region ROFR Acceptance Rates
     70.00%



     60.00%



     50.00%


                                                                                                                                2006
     40.00%
                                                                                                                                2007


     30.00%
                                                                                                                                2008



     20.00%



     10.00%



      0.00%
                                               ay



                                                     ne



                                                              ly




                                                                                                         r
                                   ch
                y




                                                                       t
                                          il




                                                                                                                   r
                                                                                    r



                                                                                              er
                            ry




                                                                     us




                                                                                                       be



                                                                                                                 be
                                                                                   be
                                           r
                ar




                                                             Ju
                                        Ap




                                                                                            ob
                       ua



                                 ar




                                               M



                                                    Ju
              nu




                                                                                                     em
                                                                      g




                                                                                                               em
                                                                                  m
                                 M




                                                                   Au




                                                                                        ct
                       br




                                                                             te
          Ja




                                                                                                    ov
                                                                                        O




                                                                                                              ec
                     Fe




                                                                              p
                                                                           Se




                                                                                                   N



                                                                                                             D
                                                          Month




                                                    Proprietary
ROFR Passive Decline Rates
TRICARE West Region Health Leadership Conference                                                                    February 26, 2009



                                    West Region Passive Decline Rate
40.00%



35.00%



30.00%



25.00%
                                                                                                                               2006


                                                                                                                               2007
20.00%

                                                                                                                               2008

15.00%



10.00%



 5.00%



 0.00%
                                          ay



                                                   ne



                                                            ly




                                                                                                          r
                              ch
           y




                                                                        t
                                     il




                                                                                                                    r
                                                                                     r



                                                                                               er
                       ry




                                                                   us




                                                                                                        be



                                                                                                                  be
                                                                                    be
                                      r
           ar




                                                          Ju
                                   Ap




                                                                                             ob
                  ua



                            ar




                                          M



                                               Ju
         nu




                                                                                                      em
                                                                    g




                                                                                                                em
                                                                                   m
                            M




                                                                 Au




                                                                                         ct
                  br




                                                                              te
     Ja




                                                                                                     ov
                                                                                         O




                                                                                                               ec
                Fe




                                                                               p
                                                                            Se




                                                                                                    N



                                                                                                              D
                                                        Month


                                                   Proprietary
Right of First Refusal Results – West Region November 2008
TRICARE West Region Health Leadership Conference                              February 26, 2009



           MTF    Accepted by MTF     Active Decline   Passive Decline   Accepted Rate
 HAWAII MARKET
 Tripler                         46                38                4           51.11%
 ALASKA MARKET
 Elmendorf                        9                28                0           23.08%
 NORTHWEST MARKET
 Madigan                         89               152               14           34.36%
 Bremerton                       21                19                0           52.50%
 SOUTHWEST MARKET
 NMCSD                          605                 6                0           98.37%
 Camp Pendleton                 285                11                7           93.44%
 Nellis                          13                23                2           34.21%
 Travis                         237                30               20           75.24%
 CENTRAL MARKET
 Ft. Carson                      23                50                4           28.75%
 USAFA                           46                35                9           51.11%
 Ft. Riley                       17                59                2           21.52%
 Offutt                          14                53                3           20.00%
 Ft. Leonard Wood                 6                20                2           20.69%
 MOUNTAIN MARKET
 Luke                             6                34                4           13.04%
 Davis Monthan                   40                11                6           63.49%
 Kirtland                         5                21                0           19.23%
 William Beaumont                 7                74                7            7.78%
 Total            1498 (62.16%)     741 (30.75%)      106 (4.40%)

 * Only high-volume MTFs are listed

                                                   Proprietary
 Quality Review Tool (QRT) Results
 TRICARE West Region Health Leadership Conference                                             February 26, 2009




                                         Overall Results
                                    October - December 2008
                     Number of Referrals       Number Audited              Percent Accurate     Goal

West Region                        140,226                        10,012             99.39%          98.00%

Alaska Market                         5,175                        1,087             99.72%          98.00%

Central Market                       45,209                        2,488             99.43%          98.00%

Hawaii Market                         4,420                         388              99.72%          98.00%

Mountain Market                      39,163                        1,438             99.30%          98.00%

Northwest Market                     11,482                        1,183             99.39%          98.00%

Southwest Market                     28,628                        3,128             99.22%          98.00%




                                                    Proprietary
Care Coordination Program




           Proprietary
Care Coordination
TRICARE West Region Health Leadership Conference                 February 26, 2009




• Care Coordination is Provided to MTF
  Beneficiaries Referred to Community-based
  Providers for Certain Surgical Procedures and
  Maternity Care
• Care Coordination Supports the Goal of Clinical
  Optimization by Coordinating Arrangements for
  Services, Helping Beneficiaries and Providers
  With Discharge Planning, and Arranging for
  Post Discharge Assistance




                                                   Proprietary
Care Coordination
TRICARE West Region Health Leadership Conference                 February 26, 2009




• Care Coordination Assists At-risk Beneficiaries
  With the Coordination of Medical Care During a
  Single Episode of Care
      • Preparing patients for surgery; e.g., bariatric,
        spinal, joint procedures
      • Coordinating transfers and follow-up care
      • Clarifying discharge instructions
      • Arranging for ordered care (home care, durable
        medical equipment, etc.)
      • Evaluating post discharge status
      • Support for new mothers and babies


                                                   Proprietary
Care Coordination (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009




• Care Coordination Outcomes
      • Channeling to a network provider
      • Education and improved self-management
      • Referral to support groups and community
        resources
      • Arrange for services to improve or recover
        function
      • Referral to a health coach or a case manager
      • Assist to obtain behavioral health care
      • Optimization of MTF capabilities



                                                   Proprietary
Care Coordination (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009




• Approximately 1,700 Beneficiaries Receive
  Care Coordination Monthly
• 54 Percent of Deliveries Receive a Postpartum
  Contact
      •   Screen for postpartum depression
      •   Confirm adherence to discharge instructions
      •   Facilitate self-management
      •   Confirm new baby follow-up appointment and
          enrollment




                                                   Proprietary
Case Management Program




          Proprietary
CM Support to the MTF
TRICARE West Region Health Leadership Conference                 February 26, 2009



•       Education for MTF Staff
    •     Consultation on access/communication issues
    •     Reports regarding MTF enrolled beneficiaries
    •     On line referral form
    •     Collaboration with MTF PCM and Clinical CMs
    •     Expertise on access to civilian health and
    •      community resources
    •     Support for Service members and their families
    •     Healing Heroes Web portal
               • www.triwest.com/healingheroes




                                                   Proprietary
Case Management Program
TRICARE West Region Health Leadership Conference                                         February 26, 2009



    Case Management is a collaborative process of
    assessment, planning, facilitation and advocacy for
    options and services to meet an individual’s health
    needs through communication and available resources
    to promote quality, cost effective outcomes.
        (2002 CMSA Revised Standards of Practice)



• Case Management (CM)                                            • Specialty Programs
  Programs                                                          • Cancer Clinical Trials (CCT)
    •    Medical                                                    • Extended Care Health Option
    •    Behavioral Health (BH)                                       (ECHO)/Autism Demonstration
    •    Transplant                                                 • Hospice
    •    Traumatic Brain Injury (TBI)




                                                    Proprietary
Case Management Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009



• Medical/Behavioral CM
       • Managed in Hub offices throughout the West
         Region
• Transplant CM
       • Case Managers located in corporate office
       • Follow beneficiary through process, pre- to
         post-transplant
• Cancer Clinical Trials
       • Benefit for National Cancer Institute sponsored
         studies



                                                   Proprietary
Case Management Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009



• Hospice
       • Program mirrors Medicare
• Traumatic Brain Injury
       • Focused on enhancing care coordination for
         this special needs population
       • Collaboration with MTF/community-based
         warrior in transition unit/military medical support
         office




                                                   Proprietary
Case Management Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009


 • Medical/BH/Transplant/TBI
        • Trigger examples: spinal cord injury, residential treatment
          center
        • Voluntary and require beneficiary consent
        • Care plans developed with family input
        • Collaboration with MTFs and civilian providers
        • Advocate for beneficiary needs/wishes
        • Care plan updates to primary care manager
        • plans for beneficiary autonomy and CM discharge
        • Appropriate closure
        • Beneficiary feedback measurement (interactive voice
          response, Web, paper)
        • Case outcome measurement



                                                   Proprietary
Case Management Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009



 • Clinical Cancer Trials
        • Coordinators find studies, enroll beneficiary and
          pay claims
        • Monitor progress and continuance on study
        • May be dual managed by medical CM
 • Hospice
        • Coordinator administers the benefit




                                                   Proprietary
Case Management Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009



• TriWest CM Enrollment (As of Dec 31 08)
       •   Medical:                       1,343
       •   BH:                              287
       •   Transplant:                      198
       •   TBI:                              24
• Specialty Enrollment (As of Dec 31 08)
       • CCT:                                 166
       • Hospice:                             109
• Beneficiary Feedback (As of Sep 30 08)
       • Satisfied/Very Satisfied: 90% or greater


                                                   Proprietary
Case Management Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009



• Collaboration Opportunities
       • Communication with PCMs and MTF CMs as well
         as Veterans Administration (VA) contacts
       • Federal, state and community resources
       • Transfers between TRICARE Regions
• Resources
       • TriWest case management leadership
       • CM clinical specialist support to hub CM
       • Periodic case teleconferences
       • Variety of CM-related reports available
       • Points of contact list
       • Healing Heroes Web portal
          • www.triwest.com/healingheroes
       • CM program training/presentations to MTF staff
                                                   Proprietary
ECHO and Autism Program




          Proprietary
ECHO/Autism Support to the MTF
TRICARE West Region Health Leadership Conference                 February 26, 2009




• Subject Matter Experts Provide Telephonic
  Briefing
       • ECHO Program
       • Autism Demonstration Project
• Coordinators Assist With the Registration
  Process
• Assign an ECHO CM
• Reports Under Development




                                                   Proprietary
ECHO and Autism Program
TRICARE West Region Health Leadership Conference                 February 26, 2009



• Extended Care Health Option (ECHO)
   • Supplemental TRICARE benefit effective
     September 1, 2005
   • Replaces previous Program for Persons with
     Disabilities (PFPWD) and Cancer Clinical Trials
     (CCT) programs
   • Designed to provide additional benefits for
     beneficiaries with moderate to severe
     disabilities
   • Financial cap of $36,000/year per beneficiary
     for all services except ECHO home health
     services



                                                   Proprietary
ECHO and Autism Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009




• ECHO Eligibility Requirements
      • Active duty family member
      • Enrolled in sponsor’s Exceptional Family
        Member Program (EFMP)
      • Qualifying condition identifies a moderate-to-
        severe disability or
         • Cerebral Palsy
         • Spina Bifida
         • Blindness or hearing loss
         • Down’s Syndrome if under age 3
         • Fetal Alcohol Syndrome if under age 3



                                                   Proprietary
ECHO and Autism Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009




• Referrals to ECHO Program
      • Use the CM referral form found on
        www.TriWest.com
      • Call 1-888-TriWest (874-9378) and ask for
        geographic point of contact
         • All numbers can be found in the TRICARE
           ECHO brochure available at TRICARE
           Service Center
• When Registration is Completed, an ECHO
  CM Will Be Assigned to the Beneficiary to
  Assist With Services


                                                   Proprietary
ECHO and Autism Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009




• Services Include But Not Limited To
      • Applied Behavior Analysis (ABA) therapy
      • Durable equipment – items that cannot be
        covered under durable medical benefit under
        TRICARE Basic
      • Limited transportation to and from ECHO
        covered services
      • In-home, hourly, skilled and respite care services




                                                   Proprietary
  ECHO and Autism Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009


• Autism Demonstration Is New Program Effective
  Mar 15, 2008
• Provides Enhanced Access to ABA Services Under
  the ECHO Program
• Paraprofessional Level Tutor Supervised By a
  Certified Provider
   • Available services increased to 45 hours per
     month
   • Beneficiary must be registered in ECHO with
     diagnosis on the Autism Spectrum Disorder
      • At least 18 months of age
      • Individual Education Plan (IEP) or Individual
         Family Service Plan (IFSP)
                                                   Proprietary
ECHO and Autism Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009




• ECHO Program Enrollment (01/26/09)
      • 1481 currently enrolled
      • 217 in registration process
• Autism Demonstration Enrollment (01/31/09)
      • 216 receiving services
      • 153 arranging services
• Providers in Demonstration (01/31/09)
      • 100 ABA supervisors
      • 638 ABA tutors




                                                   Proprietary
ECHO and Autism Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009


• ECHO Registration
   • Obtain documentation from the EFMP Coordinator
      • Working with HQ Marine Corp for single
        information source
   • Obtain orders from PCM for ECHO services
      • Utilize the designated ECHO fax number to
        expedite the process
   • ECHO registration is transferable to other Regions
      • Contact ECHO CM if beneficiary is moving
      • CM communicates transfer of eligibility to new
        CM
   • Telephonic briefings available to MTF and EFMP
     staff



                                                   Proprietary
Disease Management
      Program




        Proprietary
DM Support to the MTF
TRICARE West Region Health Leadership Conference                 February 26, 2009



 • Resource Sharing
        • Educational resources
        • Network and community resources
 • Reporting/Feedback Loop
        • Communication with beneficiary, MTF and ancillary
          providers
        • Communication of MTF beneficiary in DM program
        • Support of HEDIS measures
 • Educational Support
        • In-services available regarding the DM program
        • DM program design updates
 • One-on-One Conferencing with MTF Personnel
        • Patient advocate
        • Provider’s office

                                                   Proprietary
Disease Management Program
TRICARE West Region Health Leadership Conference                 February 26, 2009



• Diabetes, Congestive Heart Failure and Asthma
  Programs (URAC Accredited)
• Value-added Depression Program
• Voluntary
• Provide 6 Months of Intensive Disease-specific
  Education with a Health Coach Registered Nurse
• Utilize the VA/DoD Clinical Practice Guidelines for
  Program Development
• Education Materials Come from Reliable Sources
  (National Institute of Health, National Heart, Lung
  and Blood Institute, and the Centers for Disease
  Control)




                                                   Proprietary
Disease Management Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009




• Total Active Beneficiaries: 1,773
      • 2,307 Diabetes
      • 1,793 Asthma
      • Beneficiary feedback results (4.8 out of 5.0 or
        96%). Goal is 92%
• Approximately 9,000 Pieces of Education
  Materials Sent From April-December 2008




                                                   Proprietary
 Disease Management Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009




• Empower Beneficiaries With Knowledge About
  Their Condition
• Encourage Behavior Changes
• Improve Self-Management Skills in
  Coordination with Provider and MTF
• Decrease Long-Term Complications
• Decrease Hospital Admissions
• Decrease Emergency Room Visits




                                                   Proprietary
Disease Management Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009



• Beneficiaries are Identified by the Department
  of Defense (DoD) Quarterly
• Beneficiaries Stratified Based Upon Utilization
  of ER, Hospital and Outpatient Visits




                                                   Proprietary
Disease Management Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009



 • Program Engagement
        • Calls are made to the beneficiary; an initial
          health survey is completed
        • During each phone visit, educational materials
          are reviewed with the beneficiary by the clinician
        • Follow-up calls made every 1-4 weeks
          depending on stratification and needs of the
          beneficiary
        • In approximately 6 months, beneficiary
          completes the intensive program
        • Follow-up calls over the next 18 months




                                                   Proprietary
Disease Management Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009



• DM Reports Available
• Each month the MTF Receives a Report From
  the DM Program via Mail
• Report Includes: Beneficiaries That Have Been
  Identified; Actively Participating; Decline and
  Complete the Program




                                                   Proprietary
Disease Management Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009

• Additional DM Services Offered
   • Diabetes Support Group
      • Registered dietitian
          • 1:1 nutrition education
          • Group classes
   • Exercise counseling
      • Exercise specialist
          • 1:1 exercise education
          • Group classes
   • HEDIS and wellness IVR reminders
      • Example: retinal exams for diabetics
   • DM Web portal
      • Healthy newsletter and educational materials
                                                   Proprietary
Disease Management Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009



 • Future Program Enhancements
 • New Interdisciplinary Team Members
    • Social worker
    • Pharmacist
    • Respiratory therapist
 • Certificates of Recognition
    • Certificates sent to beneficiary upon completion
      of all phases of the DM program
    • Encourages continued program engagement
      and job well done
 • An Interactive Voice Response (IVR) system is
   used to obtain beneficiary feedback


                                                   Proprietary
Disease Management Program (cont.)
TRICARE West Region Health Leadership Conference                 February 26, 2009




 • Offer and Provide Program Briefings and
   Onsite Visits for MTFs
 • Refer Beneficiary to MTF for Healthcare
   Services
 •     Web Portal Resources
 • Beneficiary Education Materials and Web
   Resources




                                                   Proprietary
Medical Management
 Program Oversight
Utilization Management
West Region Health Leadership Conference                      2/26/2009




Utilization Management (UM)
     – Referrals and Authorizations
        • Coordinate care with TriWest on unique cases
        • Respond to MTFs – policy, contract clarifications
        • Review contract required reports
     – Right of First Refusal (ROFR)
     – Utilization Management Activities
        • Retrospective Studies (ER overutilization)
        • Care Coordination
           ▪ Complex cases
           ▪ Post Service Nursing Calls
Case Management/Disease Management
West Region Health Leadership Conference                2/26/2009


Case Management (CM)
    • Transfers – Cross regions, unique
    • Complex Cases
Special Needs/Extended Care Health Options (ECHO)
    •   ADFM with disabilities
    •   Autism Demonstration
    •   Respite Care
    •   ECHO Home Health
Disease Management (DM)
    • Current Diseases (Asthma, CHF, Diabetes)
    • New NDAA Disease states
         Chronic Obstructive Pulmonary Disease (COPD)
         Cancer Screening
         Depression/Anxiety
Medical Management Resource
West Region Health Leadership Conference               2/26/2009



     Research issues and questions pertaining to the
     interpretation of:

          TRICARE Operations Manual (TOM)
          TRICARE Reimbursement Manual (TRM)
          TRICARE Policy Manual (TPM)
          Code of Federal Regulations (CFR)
          West Region Contract
          Office of General Counsel (TMA)
          Contracting Officer
          Medical Benefits & Reimbursements (MB&Rs)
Medical Management Resource
West Region Health Leadership Conference    2/26/2009




Evaluate Reports and Surveys
     • Determine efficacy
     • Contract requirements
     • Survey feedback

Evaluate Medical Management Program Plans
Identify and Resolve Trends
Contract changes and modifications
Medical Management Resource
West Region Health Leadership Conference                 2/26/2009




Memorandums of Understanding (MOUs)
     Attachments
        C- MTF Capability
        E2 - UM & Case Management
        E3 – Referrals & Authorizations/ROFRs
        E4 - Populations Health and Disease Management
        E5 – After Hours/Urgent Care
        E6 – Behavioral Health
        K – Consult Tracking
        L – MTF/TriWest/TROW Points of Contact

				
DOCUMENT INFO