MEDICAID SAVINGS TEMPLATES™

Description

The Identify Candidate Case business process has two tracks of activity: (A) the original Framework 2.0 surveillance and utilization review process, and (B) a new pro-active cost containment problems analysis process.

 A)  Surveillance and utilization review uses State-specific criteria and rules to identify target populations (e.g., providers, contractors, or beneficiaries), establishes patterns or parameters of acceptable/unacceptable behavior, tests individuals against these models, or looks for new and unusual patterns, in order to identify outliers that demonstrate suspicious utilization of program benefits.

Candidate cases may be identified for:

·       Provider utilization review

·       Contractor

·       Beneficiary utilization review

·       Potential fraud

·       Drug utilization review

·       Quality review

Each type of case is driven by different State criteria and rules, different relationships, and different data.

B)  Pro-active cost containment problems analysis uses comparative and trended program and utilization analysis to identify target populations (e.g., providers, contractors, or beneficiaries), establishes patterns or parameters for identifying cost-containment vulnerabilities, tests populations and individuals against these models, and confirms new and unusual patterns, in order to confirm cost containment problems, identify interventions, and refer cases for action/implementation.

Business Process Model location:

Tier 1:

Program Integrity Management

Trigger Event

A)   For surveillance and utilization review:

1.   Scheduled time to scan for candidate cases

2.   Request to examine a specific group or individual

3.   Referrals from cost containment problems analysis

4.   An alert triggered by other events

B)   For cost containment problems analysis

1.   Regularly scheduled vulnerabilities analysis

2.   Referrals of program problems for review

3.   Surveillance and utilization review triggers

Result

For both Tracks:

1.   List of individual provider and recipient candidate cases for case-by-case action.

2.   Case documentation for confirmed cost-containment problems with recommended interventions for correction

3.   Record of criteria for targeted populations, data selection, and parameters and analyses used

Business Process Steps

A)   For surveillance and utilization review

1.   Identify target population — Define characteristics of the population in which the search will focus: types of provider, location, types of services, patient characteristics, medical conditions

2.   Identify data requirements — Specify time period, data elements, data relationships to include in the search

3.   Identify rules to apply to the data — Select or create rules including specified norms, statistical deviations, types of patterns, Boolean logic, ratios, percentages

4.   Apply rules to target population data — Execute rules and record results

B)   For cost containment problems analysis

1.   Identify target population for potential cost containment vulnerabilities through comparative cross state Medicaid analysis, other external data analysis, and program experience review

2.   Confirm cost-containment problems in specific services for particular populations of recipients and providers through various types of utilization and other analyses

3.   Match confirmed problems to characteristics of particular interventions and their capabilities.

4.   Develop recommendations for intervention and for monitoring intervention results.

Shared Data

For both processes:

1.       Member, provider, and service history data stores

2.       Rules database

Predecessor

For both processes:

1.       Maintain schedule for case (and problem) identification

2.       Receive special request for review

3.       Receive warning to investigate

Successor

A)   For surveillance in utilization review

·         Research candidate case (in PI2 Manage Case)

B)   For cost containment problems analysis

1.   Develop intervention plans (in PI2 Manage Case) for cost containment problems requiring program interventions

2.   Research candidate case (in PI2 Manage Case) for referrals for case-by-case actions

Constraints

States and programs within states establish different criteria for their investigations. Rules change along with the experience of the state, changes in benefits, new provider types. Problem confirmation may require additional clinical and other data not readily available.

Failures

N/A

Performance Measures

A)   For surveillance and utilization review (none in MITA)

B)   For cost containment problems analysis performance measures are the same as for cost-containment interventions implementation in PI2, since tracks B of PI1 and PI2 represent an integrated process:

1.   Attainment of projected savings tracked intervention by intervention

2.   Maintenance of access and quality of care tracked against selected HEDIS Medicaid and specific state-determined measures

Description

The Manage Case business process has two tracks of activity:  (A) the original surveillance and utilization review case management track, and (B) a new pro-active cost containment interventions implementation track.

A)  Surveillance and utilization review receives a case file from an investigative unit with the direction to pursue the case to closure. The case may result in civil or criminal charges, in corrective action, in removal of a provider, contractor, or beneficiary from the Medicaid program; or the case may be terminated or suspended. Individual State policy determines what evidence is needed to support different types of cases:

·         Provider utilization review

·         Provider compliance review

·         Contractor utilization review

·         Contractor compliance review

·         Beneficiary utilization review

·         Investigation of potential fraud

·         Drug utilization review

·         Quality review

·         Performance review

Each type of case is driven by different criteria and rules, different relationships, and different data. Each type of case calls for different types of external investigation.

B)  Pro-active cost containment interventions implementation receives confirmed problems analyses and intervention recommendations, reviews them all with appropriate Medicaid and other staff, and manages their implementation in coordination with other program units. seeks executive authorization to implement the recommended interventions,  documentation analysis uses comparative and trended program and utilization analysis to identify target

Business Process Model location:

Tier 1:

Program Integrity Management

Trigger Event

A)   For surveillance and utilization review:

1.   Scheduled time to perform case management

2.   Receipt of information requiring case management

3.   Special request to perform case management

B)   For cost containment problems analysis

·         Receipt of confirmed problem reports and interventions recommendations

Result

A)   For surveillance and utilization review:

1.   Record of documentation

2.   Disposition of case

B)   For cost containment problems analysis

1.       Implementation of recommended interventions

2.       Capture of projected savings

Business Process Steps

A)   For surveillance and utilization review:

1.   Assign case manager — A case manager is assigned and authorized to manage a case and request additional information

2.   Establish case — The case file is opened, a schedule is added, and a reporting framework is established

3.   Review case — Examine information associated with the case; request more historical information as needed

4.   Notify affected parties — Correspond with providers, beneficiaries, agents, guardians, attorneys, et al to notify them regarding the investigation, their rights, and the right of the Medicaid agency to request documentation

5.   Conduct inquiries and investigations — Depending on the type of case, different external inquiries will need to be conducted, e.g.,

a.   View medical records

b.   Interview patient

c.   Validate credentials

6.   Document evidence — Evidence is documented in the case file

7.   Determine action — Based on evidence gathered, a determination is made to close the case

8.   Determine disposition — When research and analysis are completed, the case disposition is reported, e.g., cancel case, claim damages, identify corrective action, terminate membership in Medicaid program

B)   For cost containment problems analysis

1.   Review confirmed problem report and intervention recommendations with Medicaid and other staff responsible for program or operations units involved

2.   Seeks executive authorization to implement the recommended interventions

3.   Coordinate implementation with responsible program and/or operations units

4.   Monitor implementation to assure savings are captured and the access and quality of care are unaffected

5.   Identify the need for and make mid-course corrections should interventions encounter unanticipated problems for the healthcare market respond in unanticipated ways

Shared Data

Member, provider, and service history data stores

Rules data base

Medical records

Program follow season procedures

Automated systems documentation

Predecessor

A)   For surveillance and utilization review:

1.   Research Candidate Case (in PI1)

2.   Develop cost containment intervention recommenda­tion (in PM1) when recommendations include recipient and or provider cases for individual action

B)   For cost containment problems analysis

·         Develop cost containment intervention recommenda­tion (in PM1)

Successor

A)   For surveillance and utilization review

1.       Prepare Outgoing Information

2.       Support Grievance and Appeals

B)   For cost containment problems analysis

1.   Develop & Maintain Benefit Package (PG3) when benefits require changes

2.   Develop & Maintain Program Policy (PG4) when policies require changes

3.   Manage Rate Setting (PG2) when rates require changes

4.   Authorize Services (OM2) when access to services requires limitations

5.   Audit Claim/Encounter (OM6) when claims processing changes or limitations are required

Constraints

States and programs within states establish different criteria for their investigations. Rules change along with the experience of the state, changes in benefits, new provider and beneficiary types. Interventions may require considerable implementation work and monitoring.

Failures

N/A

Performance Measures

A)   For surveillance and utilization review (none in MITA)

B)   For cost containment problems analysis

1.   Attainment of projected savings tracked intervention by intervention

2.   Maintenance of access and quality of care tracked against selected HEDIS Medicaid and specific state-determined measures