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.