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Pricing Strategies for Medical Staffing - Download as PDF

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Utilization Management & Capitation Strategies - 2011 Edition

Description:    A 504 page toolbox of UM model policies, procedures and plans that ‘work’ with P & Ps for
                traditional, streamlined, open access and other cost-effective management strategies. Contact
                capitation and other variations of traditional capitation compensation strategies are detailed. Case
                management and quality management programs. Resources include utilization management
                program example format, audit policies and forms, contract analysis formats, numerous forms
                benchmarks, job descriptions, legal resources and case citations, links to authoritative national
                guideline resources, references and a glossary of managed care terms

                This manual has been developed to provide a model for methods to ‘manage care’ more effectively
                and efficiently. The relatively unmanaged, unstructured and unsupervised medical care system of
                two to three decades ago has evolved to require expert medical management, structure based on a
                clearly defined objective rationale and sophisticated oversight. Understanding the clinical ‘decision
                support criteria’ or ‘review criteria-guideline’ approach to either implementing or judging
                appropriateness and medical necessity is essential to be a viable participant in the business of
                patient care. Early recognition, appropriate and necessary evaluation and treatment, and needed
                follow-up care are the keys to a quality-based, cost-effective model of care for any condition.

                “These guidelines are an educational tool designed to assist practitioners in providing appropriate
                care for patients. They are not inflexible rules or requirements of practice and are not intended, no
                should they be used, to establish a legal standard of care. … The ultimate judgment regarding the
                propriety of any specific procedure or course of action must be made by the physician” (or other
                care provider) “in light of all the circumstances presented. Thus, an approach that differs from the
                guidelines, standing alone, does not necessarily imply that the approach was below the standard of
                care. To the contrary, a conscientious practitioner may responsibly adopt a course of action
                different from that set forth in the guidelines when, in the reasonable judgment of the practitioner,
                such course of action is indicated by the condition of the patient, limitations on available resources
                or advances in knowledge or technology subsequent to publication of the guidelines. However, a
                practitioner who employs an approach substantially different from” nationally accepted “guidelines
                is advised to document in the patient record information sufficient to explain the approach taken.
                The practice of medicine involves not only the science, but also the art of dealing with the
                prevention, diagnosis, alleviation and treatment of disease. The variety and complexity of human
                conditions make it impossible to always reach the most appropriate diagnosis or to predict with
                certainty a particular response to treatment. It should be recognized; therefore, that adherence to
                these guidelines will not assure an accurate diagnosis or a successful outcome. All that should be
                expected is that the practitioner will follow a reasonable course of action based on current
                knowledge, available resources, and the needs of the patient to deliver effective and safe medical
                care.” [selections within quote marks by the American College of Radiology, preamble to individual
                guidelines, 2002)

                Each example policy and procedure/review criteria/guideline throughout this manual should be
                reviewed by the medical policy (or similar) committee and modified or adapted as appropriate to fit
                local circumstances. It is strongly recommended that all applicable documents that will be used to
                manage medical care in the organization be sent to affected providers for review and comment
                prior to implementation. This will always promote an understanding of the policy, procedure,
                criteria or guideline, avoid compliance issues, and frequently improve the document by added

                This manual does not provide legal counsel or advice. There is no uniform universal contract
                language. Applicable laws vary from state to state and in some cases, from locality to locality.
                Every physician requires the availability of expert legal and accounting advice to manage the
                business aspects of their practice.

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; Medicare is targeting costly physicians

- 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;
Tracking new federal regulations;

- 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

- 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; Out-of-Pocket (OP)
Patient Expenses; Outpatient surgical authorizations, procedure; Podiatry Services;

- Referral Authorization Strategies – ‘Passthroughs’ or ‘Automatic’ Approval or ‘Direct Access’ –
example list; Streamline referral process; ‘Open Access’ + 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 +
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

            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

            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+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

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Description: Pricing Strategies for Medical Staffing document sample