For the purpose of this section, the
term “contractor” applies to the Managed Care Support (MCS) contractor
and Uniformed Services Family Health Plan (USFHP) Designated Providers
(DPs).
1.0 Scope
1.1 The provider PMP is a quarterly review of all
providers who prescribed controlled substances prescriptions, such
as opioids, for beneficiaries using TRICARE benefits. The goals
of the program are to:
1.1.1 Maintain compliance with the
guidelines described within
32 CFR 199.4;
1.1.2 Monitor provider prescribing practices of controlled
substances, such as, but not limited to, opioids;
1.1.3 Ensure providers are practicing within the
appropriate clinical practice guidelines according to specialty
and disease/condition.
1.1.4 Provide education and resources
to providers when needed; and
1.1.5 Improve communication with
providers and increase safety and effectiveness of treatment.
1.2 The contractors shall designate a “reviewer”.
The reviewer shall be a contractor’s Chief Medical Officer (CMO)
or a person approved by the CMO. The reviewer shall have the appropriate
credentials to review standard of care determinations (see
Chapter 7, Section 1, paragraph 3.1.1). The
reviewer shall review providers on the quarterly report (see
paragraph 2.1)
and make determinations based upon prescribing practices seen over
the duration of the report. The reviewer shall conduct a medical
review of the provider’s prescribing history to validate the practices
with the medical diagnosis and patient overdose history, appropriateness
of care, and to ensure the prescription(s) were written and dispensed in
support of a legitimate medical purpose. The level of review necessary
is the breadth and depth needed to make an accurate determination.
It may include claims review, record review, cross referencing with
other applicable program, such as the PMP, or any other relevant
information as necessary to make an accurate determination. Any
inconsistencies with prescribing and medical diagnosis and/or over-prescribing
concerns for the medical diagnosis noted by the reviewer shall necessitate
the contractors to develop an intervention plan. An intervention
plan shall be an alert to the provider and lead to education, training,
and appropriate referrals to the contractors’ Quality and/or Program
Integrity departments. At a minimum, the intervention plan shall
be an alert to the provider to participate in education consistent
with industry best practice and standard of care clinical practice guidelines,
such as, the Center for Disease Control and Prevention (CDC) and
Veterans Health Administration (VHA)/Department of Defense (DoD)
related guidelines, provide contractually available resources to
complement or manage the provider’s patient population, and present
knowledge and training opportunities to support the provider’s prescribing
practices. Providers shall be educated on the Substance Abuse and
Mental Health Services Administration (SAMHSA) training, such as buprenorphine
training, to practice Medication Assisted Treatment (MAT) when appropriate
as outlined in
paragraph 3.0.
1.3 Contractor shall develop a process to include
timelines in which targeted providers acknowledge the alert, education,
and intervention plan consistent with nationally recognized clinical practice
guidelines and recommendations (U.S. Department of Health and Human
Services (HHS), CDC, etc.). Results of the providers’ responses
are identified in DD Form 1423, Contract Data Requirements List
(CDRL), located in Section J of the applicable contract.
1.4 Contractor’s medical review and intervention
decisions are subject to review by the Government.
1.5 The Government has the right to request the
contractor to conduct a clinical quality review, case investigation,
and report their findings to the Government. The Government may
request the contractor to take necessary steps to safeguard the
safety of TRICARE beneficiaries.
2.0 Initial
Review and Intervention SERVICES
2.1 Each quarter, the Defense
Health Agency (DHA) Pharmacy Operations Division will generate a report
for each of the contractors, a list outlining the controlled substances
prescribing practices of all providers. The bounds of generally
accepted prescribing practices will be based upon the industry’s best
practices and clinical practice guidelines for identifying and preventing
unnecessary prescribing or over-prescribing of controlled substances,
such as opioids. These parameters may evolve and are not made publicly
available. Providers that fall outside of what are considered to
be normal prescribing patterns for controlled substances shall be
subject to a more in-depth review. The data provided to the contractor
will be divided into subsets based upon region location (e.g., business
address of the provider). The report will be sent to the contractors
for medical review. The report will flag providers as new or existing
on prior reports.
2.2 During the quarter, if concerns
about provider prescribing controlled substances are identified by
other entities or reviewers in the course of business, the contractors
shall provide a medical review to determine potential unnecessary
prescribing or over-prescribing. These shall be given priority over the
quarterly list and may be counted towards the minimum review per
quarter.
2.3 The
contractors shall coordinate efforts with other TRICARE contractors
as needed, such as when a provider may see TRICARE beneficiaries
from another region, or overseas locations.
2.4 The contractors shall prioritize and review
a minimum of 0.5% of the top and/or outlying prescribing practices
or an amount designated by DHA not to exceed 100 cases per quarter
from the quarterly list. Providers associated with beneficiaries
identified in the Beneficiary PMP shall be prioritized for review.
Contractor shall select varying medical conditions and physician
specialty types unless directed by DHA. See
paragraph 2.5 for responses,
and
paragraph 2.6 for responses that count towards
the minimum review.
2.5 At
a minimum, each contractor shall review the data generated on the
quarterly report and provide a response in the following manner:
• No
Action (provider’s prescribing deemed appropriate)
• Intervention plan
with education only
• Intervention plan
with escalation
• Further monitoring
needed
• Not
Reviewed
2.6 Each provider
shall be documented as no action, intervention plan with education
only or escalation count towards cases reviewed. Previously reported
providers will be identified and flagged in the generation of a
new report for the next quarter for trending across quarters, and
when further monitoring is needed.
3.0 Interventions
3.1 Interventions shall be initiated no later than
the following quarter after the initial quarterly review.
3.2 Intervention Plan With Education
Only
3.2.1 Based upon the outcome of the review, the contractor
shall target the individual TRICARE provider with interventions.
In cases where interventions are deemed appropriate the contractors
shall use industry best practices to intervene and educate providers.
At a minimum, the intervention plan shall include:
• An alert to the individual
provider to include Clinical Practice Guideline education, such
as the CDC, VHA DoD, and nationally recognized professional organizations’
recommended guidelines;
• Contractually
available resources or other covered TRICARE benefits to complement
their patient population (such as covered Substance Use Disorder
(SUD) and mental health treatment, covered alternative pain-related
medication and treatments, and applicable supportive clinical programs);
and
• Knowledge and training
opportunities to support the provider, such as national and state Prescription
Drug Monitoring Programs (PDMP) and SAMHSA training, such as buprenorphine
training, to provide MAT when appropriate.
3.2.2 The contractor shall direct
targeted providers to their website for educational materials dedicated
to support providers that prescribe controlled substances, such
as opioids. Contractors shall use existing provider information
modalities (i.e., newsletters, email blasts, etc.) to disseminate information
to educate providers.
3.2.3 Contractor intervention plan
with education materials shall be made available to the Government
and subject to review by the Government.
3.3 Intervention Plan With Escalation
The contractor shall initiate an intervention
plan with escalation when there are concerns of a clinical variance
warranting further review and investigation for determination of
the presence of an actual Quality Issue (QI) or potential fraud;
and shall initiate suspension, denial, and recoupment of claims
when a possible drug abuse situation is identified and/or warranted.
5.0 REPORTS
5.1 The contractor (excluding
Military Treatment Facilities (MTFs)/Enhanced Multi-Service Markets (eMSMs))
shall provide to the Government a quarterly summary status report
of all reviewed and targeted providers to include provider name,
summary of the clinical review, number of interventions, type of
interventions, and number not provided intervention (e.g., dosing
and prescriptions were deemed appropriate) and provide rationale
(e.g., cancer clinic). See
paragraph 1.2. Details for reporting are identified
in DD Form 1423, CDRL, located in Section J of the applicable contract.
5.2 Contractors with physician
portals shall maintain a searchable database of patients currently
on a PMP restriction in their secured website and make available
to their network providers. These physician portals shall be compliant
with Health Insurance Portability and Accountability Act (HIPAA) Privacy
standards, HIPAA Electronic Transaction standards, and any other
applicable Federal regulations.