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.