Medical Management (MM), Utilization Management (UM), And Quality Management (QM)
1.0 MM/UM
Program Plan
The Defense
Health Agency (DHA) defines MM as an integrated managed care model
that promotes UM, Case Management (CM), and chronic care/Disease
Management (DM) programs as a hybrid approach to managing patient
care. MM integrates evidence-based and outcome-oriented programs
into the MM processes.
1.1 These
requirements are applicable to utilization and quality review of
all health care services delivered to all beneficiaries living within
the region, to all beneficiaries receiving care in the Region regardless
of their place of residence, and to all providers delivering care
within the region. Additional requirements for enrollees (such as
authorizations for specialty care are found throughout 32 CFR 199 and
the TRICARE Manuals) and network providers (such as qualifications
to be network providers are further identified in
Chapter 5 and
the TRICARE Policy Manual (TPM)). All providers shall be subject
to the same review standards and criteria. The contractor shall
be considered a multi-function Peer Review Organization (PRO) under
this contract.
1.2 The
contractor shall fully describe in a written MM/UM Plan all processes,
procedures, criteria, staff and staff qualifications, and information
and data collection activities and requirements the contractor shall
use in conducting MM/UM activities.
Details
for
providing this plan are
identified
by DD Form 1423, Contract Data Requirements List
(CDRL)
, located in Section J of the applicable contract.
1.2.1 The DHA Program
Office (Clinical Operations Division (COD)/TRICARE Overseas Program Office)
will review the plan and make recommendations for
revision if necessary within 45 calendar days or provide written
approval through the Contracting Officer (CO). In the absence of MM/UM staff in
the Uniformed Services Family Health Plan Program
Office (USFHP PO), the DHA Clinical
Support Division (CSD) will review the plans submitted and
provide recommendations for revision or written acceptance within
45 days.
1.2.2 The
contractor shall provide a revised plan addressing the recommendations
within 15 business days to the appropriate reviewing office which,
will provide written approval of the plan through the appropriate
CO within 45 calendar days if there are no recommendations or upon
receipt of a revised plan which addresses the recommendations.
1.2.3 The
contractor shall participate in DHA sponsored medical management
training as requested, to include coordination of training schedules
and the development of the agenda and training schedules and the
development of the agenda and training materials. Each contractor
shall participate in two four-day training sessions per year in
their respective region. The location of the training will be designated
by DHA.
2.0 Notification Of Review Requirements
The
contractor is responsible for education and training to providers
and beneficiaries on the requirements of the MM/UM programs. The
contractor shall describe fully the process for notification, in
a timely manner (but not less than 30 calendar days prior to commencement
of review), of all providers, both network and non-network, of all
review requirements such as:
• Preauthorization;
• Concurrent
review;
• Retrospective review (including
the fiscal penalties for failing to obtain review authorizations);
and
• Review criteria to be used,
and requirements for CM.
3.0
Reviewer
qualifications and participation
3.1 Peer
Review By Physicians
3.1.1 Except
as provided in
paragraph 3.1.2, each person who makes an
initial
or reconsideration denial determination
or standard of care determination about services furnished or proposed
to be furnished by a licensed doctor of medicine or osteopathy or
by a doctor of dentistry must be another licensed doctor of medicine
in a like specialty, or osteopathy in a like specialty, or
dentistry
with an active clinical practice in the PRO area, if the initial,
reconsideration, or standard of care determination is based on lack
of medical necessity or other reason relative to reasonableness,
necessity, or appropriateness.
3.1.2 If
a PRO determines that peers are not available, then
a nationally accredited external independent review organization
shall be used to make the determinations.
3.2 Peer Review By Health Care
Practitioners Other Than Physicians
Health care practitioners other
than physicians may review services and/or make standard of care
determinations for services furnished
by other practitioners in the same professional field and specialty.
3.3 Diagnosis Related Group (DRG)
Validation Review
3.3.1 Decisions
about procedural and diagnostic information must be made by physicians.
3.3.2 Technical coding issues must
be reviewed by individuals with training and experience in International
Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM) coding (for outpatient services with dates of service
or inpatient services with dates of discharge provided before the
mandated date, as directed by Health and Human Services (HHS), for
International Classification of Diseases, 10th Revision (ICD-10)
implementation) and in ICD-10-CM coding (for outpatient services with
dates of service or inpatient services with dates of discharge provided
on or after the mandated date, as directed by HHS, for ICD-10 implementation,
or International Classification of Diseases, 10th Revision, Procedure
Coding System (ICD-10-PCS) for inpatient services with dates of
discharge provided on or after the mandated date, as directed by
HHS, for ICD-10 implementation).
3.4 Persons
Excluded From Review
3.4.1 A person may not review health
care services or make initial denial determinations or changes as
a result of DRG validations if he or she, or a member of his or
her family:
• Participated
in developing or executing the beneficiary’s treatment plan;
• Is a member
of the beneficiary’s family; or
• Is a governing
body member, officer, partner, 5% or more owner, or managing employee
in the health care facility where the services were or are to be
furnished.
3.4.2 A member
of a reviewer’s family is a spouse (other than a spouse who is legally
separated under a decree of divorce or separate maintenance), child
(including a legally adopted child), grandchild, parent, or grandparent.
3.5 Administrative Requirements
Each
review shall be dated and include the signature, legibly printed
name, clinical specialty, and credentials of the reviewer. Each
reviewer shall include rationale for his or her decision (i.e.,
a complete statement of the evidence and the reasons for the decision).
4.0
Written
Agreements With Institutional Providers
The contractor shall establish
written agreements with each institutional provider over which the
contractor has review authority. These agreements shall be maintained
throughout health care delivery. Agreements must specify that:
• Institutional
providers will cooperate with the contractor in the assumption and
conduct of review activities.
• Institutional
providers will allocate adequate space for the conduct of on-site
review.
• Institutional providers will
deliver to the contractor a paper or electronic copy of all required
information within 30 calendar days of a request for off-site review.
• Institutional
providers will provide all beneficiaries, in writing, their rights
and responsibilities (e.g., “An Important Message from TRICARE”
(
Addendum A), “Hospital Issued Notice of Noncoverage”
(
Addendum B).
• Institutional
providers will inform the contractor within three working days if
they issue a notice that the beneficiary no longer requires inpatient
care.
• Institutional providers will
assure that each case subject to preadmission/pre-procedure review
has been reviewed and approved by the contractor.
• Institutional
providers will agree, when they fail to obtain certification as
required, that they will accept full financial liability for any
admission subject to preadmission review that was not reviewed and
is subsequently found to be medically unnecessary or provided at
an inappropriate level (
32 CFR 199.15(g)).
• The
contractor shall reimburse the provider for the costs of providing
documents using the same reimbursement as Medicare.
• The
contractor shall provide detailed information on the review process
and criteria used, including financial liability incurred by failing
to obtain preauthorization.
5.0 Benefit Policy Decisions
TRICARE
versus local policy. TRICARE policies have precedence over any local
or internal policy of the contractor or the medical community of
the region. However, the contractor shall notify DHA promptly of
any conflicts between TRICARE policy and local policy. Variations
from policy, which expand, reduce, or adjust benefit coverage shall
be referred to DHA for approval before being implemented.
6.0 Concurrent Review Requirements
The
contractor shall conduct concurrent review for continuation of inpatient
mental health services within 72 hours of notification of emergency
admissions, and authorize, as appropriate, additional days.
7.0 Retrospective Reviews Related
To DRG Validation
7.1 The
contractor shall conduct quarterly focused reviews of a 1% sample
of medical records to assure that reimbursed services are supported
by documentation in the patient’s medical record. This review must
determine if the diagnostic and procedural information and discharge
status of the patient as reported by the hospital matches the attending
physician’s description of care and services documented in the patient’s
record. In order to accomplish this, the contractor shall conduct
the following review activities:
7.2 Review
of claim adjustments submitted by hospitals which result in the
assignment of a higher weighted DRG (see
Addendum C).
7.3 Review
for physician certification as to the major diagnosis and procedures
and the physician’s acknowledgment of a penalty statement on file.
7.4 When the claim is submitted,
the hospital must have on file a signed and dated acknowledgment
from the attending physician that the physician has received the
following notice:
“Notice to Physicians: TRICARE
payment to hospitals is based in part on each patient’s principal
and secondary diagnoses and the major procedures performed on the patient,
as attested to by the patient’s attending physician by virtue of
his or her signature in the medical record. Anyone who misrepresents,
falsifies, or conceals essential information required for payment
of Federal funds may be subject to fine, imprisonment, or civil
penalty under applicable Federal laws.”
7.5 The acknowledgment must be
completed by the physician either before or at the time that the physician
is granted admitting privileges at the hospital, or before, or at
the time the physician admits his or her first patient. Existing
acknowledgments signed by physicians already on staff remain in
effect as long as the physician has admitting privileges at the
hospital.
7.6 Outlier Review
Claims
that qualify for additional payment as a cost-outlier shall be subject
to review to ensure that the costs were medically necessary and
appropriate and met all other requirements for payment. In addition,
claims that qualify as short-stay outliers shall be reviewed to
ensure that the admission was medically necessary and appropriate
and that the discharge was not premature.
7.7 Procedures Regarding Certain
Services Not Covered By The DRG-Based Payment System
In
implementing the quality and utilization review for services not
covered by the DRG-based payment system, the requirements of this
section shall pertain, with the exception that the ICD-10-CM and
ICD-10-PCS codes will be used to provide basis of correct information
for dates of discharge beginning on or after the mandated date,
as directed by Health and Human Services (HHS), for ICD-10 implementation.
8.0 Retrospective
Review Requirements For Other Than DRG Validation
The contractor shall conduct
and report quarterly focused reviews of a statistically valid sample or
30 records, whichever is greater, of medical records to determine
the medical necessity and quality of care provided, validate the
review determinations made by review staff, and determine if the diagnostic
and procedural information and/or discharge status of the patient
as reported on the hospital and/or professional provider’s claim
matches the attending physician’s description of care and services
documented in the medical record. The specific types of records
to be sampled shall be determined separately by the Director, TROs
who will provide the contractor with the sampling criteria (DRG,
diagnosis, procedure, Length-Of-Stay (LOS), provider, incident or
occurrence as reported on claim forms) and the time frame from which
the sample is to be drawn 60 calendar days prior to each quarter. For
all cases selected for retrospective review, the following review
activities shall occur:
8.1 Admission
Review
The medical
record must indicate that inpatient hospital care was medically
or psychologically necessary and provided at the appropriate level
of care.
8.2 Invasive
Procedure Review
The performance
of unnecessary procedures may represent a quality and/or utilization problem.
In addition, the presence of codes of procedures often affects DRG
classification. Therefore, for every case under review, the medical
record must support the medical necessity of the procedure performed.
For this purpose, invasive procedures are defined as all surgical
and any other procedures which affect DRG assignment.
8.3 Discharge Review
Records
shall be reviewed using appropriate criteria for questionable discharges
or other potential quality problems.
8.4 Mental
Health Review
The
contractor shall review all mental health claims consistent with
how it reviews other medical/surgical claims in accordance with
the provisions in
32 CFR 199.4(a)(11).
8.5 Details
for reporting all quarterly focused
review reports are identified by DD
Form 1423, CDRL, located in Section J of the applicable
contract.
9.0 Review Results
9.1 Actions
As A Result Of Retrospective Review Related To Individual Claims
If
it is determined, based upon information obtained during reviews,
that a hospital has misrepresented admission, discharge, or billing
information, or is found to have quality of care defects, or has
taken an action that results in the unnecessary admission of an
individual entitled to benefits, unnecessary multiple admission
of an individual, or other inappropriate medical or other practices
with respect to beneficiaries or billing for services furnished
to beneficiaries, the contractor shall, as appropriate:
• Deny payment
for or recoup (in whole or in part) any amount claimed or paid for
the inpatient hospital and professional services related to such
determination.
• Require the hospital to take
other corrective action necessary to prevent or correct the inappropriate
practice.
• Advise the provider and beneficiary
of appeal rights, as required by
Chapter 12, Section 4, paragraph 2.0.
9.2 Findings Related To A Pattern
Of Inappropriate Practices
The contractor shall notify
DHA of the hospital and practice involved in all cases where a pattern
of inappropriate admissions and/or billing practices, that have
the effect of circumventing the TRICARE DRG-based payment system,
is identified.
9.3 Revision
Of Coding Relating To DRG Validation
The contractor shall ensure
the application of the following provisions in connection with the DRG
validation process.
• If
the diagnostic and procedural information attested to by the attending
physician is found to be inconsistent with the hospital’s coding
or DRG assignment, the hospital’s coding on the TRICARE claim shall
be appropriately changed and payments recalculated on the basis
of the appropriate DRG assignment.
• If
the information attested to by the physician as stipulated in
paragraph 7.3 is
found not to be correct, the contractor shall change the coding
and assign the appropriate DRG on the basis of the changed coding
in accordance with the paragraph above.
9.4 Notice Of Changes As A Result
Of A DRG Validation
The
contractor shall notify the provider of changes to procedural and
diagnostic information that result in a change of DRG assignment
within 30 calendar days of the contractor’s decision. The notice
must be understandable, written in English and shall contain:
• The corrected
DRG assignment;
• The reason for the change resulting
from the DRG validation;
• A statement
addressing who is liable for payment of denied services;
• A statement
informing each party (or his or her representative) of the right
to request a review of a change resulting from DRG validation in
accordance with the provisions in
paragraph 9.5;
• The locations
for filing a request for review and the time period within which
a request must be filed; and
• A statement
concerning the duties and functions of the multi-function PRO.
9.5
Review
Of DRG Coding Change
9.5.1 A provider dissatisfied with
a change to the diagnostic or procedural coding information made
by the contractor as a result of DRG validation is entitled to a
review of that change if the change caused an assignment of a different
DRG and resulted in a lower payment. A beneficiary may obtain a review
of the contractor’s DRG coding change only if that change results
in non-coverage of a furnished service (see 42 CFR 478.15(a)(2)).
9.5.2 The contractor shall issue
written notification of the results of the DRG validation review within
60 calendar days of receipt of the request for review. In the notification,
the contractor shall summarize the issue under review and discuss
the additional information relevant to such issue. The notification
shall state the contractor’s decision and fully state the reasons
that were the basis for the decision with clear and complete rationale.
The notification shall include a statement that the decision is
final and no further reviews are available.
10.0 Prepayment Review
10.1 The contractor shall establish
procedures and conduct prepayment utilization review to address
those cases involving diagnoses requiring prospective review, where
such review was not obtained, to focus on program exclusions and
limitations and to assist in the detection of and/or control of
fraud and abuse. The contractor shall not be excused from claims
processing cycle time standards because of this requirement.
10.2 The contractor shall perform
prepayment review of all cases involving diagnoses requiring preauthorization
where review was not obtained. No otherwise covered care shall be
denied solely on the basis that authorization was not requested
in advance, except for care provided by a network provider.
10.3 The contractor shall perform
prepayment review of all DRG claim adjustments submitted by a provider
which result in higher weighted DRGs.
11.0
Case Management
(CM)
11.1 The
contractor shall establish Case Management Liaison positions to
facilitate the hand off of CM information between the MTFs/eMSMs,
civilian Primary Care Managers (PCMs), and the contractor. Case
Management Liaisons are not required to be co-located in MTFs/eMSMs;
however, specific contact information for each Case Management Liaison
shall be provided to each MTF/eMSM.
11.2 The
contractor shall provide a Case Management Liaison staff member
for each Military Treatment Facility (MTF)/Enhanced Multi-Service
Market (eMSM) to facilitate the hand off to the MTF/eMSM Direct
Care (DC) system when beneficiaries are discharged from network
provider care. Contact information for each Case Management Liaison
shall be provided in the MTF/eMSM Memorandum of Understanding (MOU).
11.3 CM shall not be accomplished
for beneficiaries eligible for Medicare Part A and enrolled in Medicare
Part B unless it is specifically contracted for inside an individual
MTF/eMSM or if the individual is part of the Individual Case Management
Program For Persons with Extraordinary Conditions (ICMP-PEC).
11.4 The
contractor shall provide MTFs/eMSMs with visibility via dashboard-based
access to all CM assignment information. At a minimum, this information
shall provide notification to the MTFs/eMSMs whenever an MTF/eMSM
Prime enrollee is assigned a Managed Care Support Contractor (MCSC)
case manager, to include the contact information for the specific
case manager assigned to the enrollee. Information that is available
via the dashboard shall be current and refreshed no less frequently
than once every 24 hours. The dashboard shall be made accessible
to authorized Government users on a continual (24/7) basis except
for scheduled downtime for system maintenance.
12.0 Confidentiality Applicable
To All MM/UM Activities, Including Recommendations And Findings
12.1 The contractor shall develop
and implement procedures, processes, and policies that meet the confidentiality
and disclosure requirements set forth in Title 10, United States
Code (USC), Chapter 55, Section 1102; the Social Security Act, Section
1160, and implementing regulations at 42 CFR 476, the Alcohol, Drug
Abuse and Mental Health Administration (ADAMHA) Reorganization Act
(42 USC 290dd-2), the Privacy Act (5 USC 552a),
32 CFR 199.15(j) and
(l). Additionally, the contractor shall display
the following message on all quality assurance documents:
“Quality
Assurance document under 10 USC 1102. Copies of this document, enclosures thereto,
and information therefrom will not be further released under penalties
of law. Unauthorized disclosure carries a possible $3,000 fine.”
12.2 Release of Information - If
an inquiry is made by the beneficiary, including an eligible family member
(child) regardless of age, the reply should be addressed to the
beneficiary, not the beneficiary’s parent or guardian. The only
exceptions are when a parent writes on behalf of a minor child or
a guardian writes on behalf of a physically or mentally incompetent
beneficiary. The contractor must not provide information to parents/guardians
of minors or incompetents when the services are related to the following
diagnoses:
• Abortion
• Substance Use Disorder (SUD)
• Sexually Transmitted Disease
• Human Immunodeficiency Virus
(HIV)/Acquired Immune Deficiency Syndrome (AIDS)
12.3 The term “minor” means any
person who has not attained the age of 18 years. Generally, the parent
of a minor beneficiary and the legally appointed guardian of an
incompetent beneficiary shall be presumed to have been appointed
the representative without specific designation by the beneficiary.
Therefore, for beneficiaries who are under the age of 18 years or
who are incompetent, a notice issued to the parent or guardian,
under established TRICARE procedures, constitutes notice to the
beneficiary.
12.4 If a beneficiary has been legally
declared an emancipated minor, they are to be considered as an adult.
If the beneficiary is under 18 years of age and is (or was) a spouse
of a Service member or retiree, they are considered to be an emancipated
minor.
13.0 Documentation
The
contractor shall develop and implement a program for providing beneficiaries
and providers with the written results of all review activities
affecting benefit determinations. All notifications to beneficiaries
and providers shall be completed and mailed within the time limits established
for the completion of reviews in this section. Notifications of
denials shall include:
• Patient’s
name;
• Sponsor’s name;
• Last four
digits of the sponsor’s Social Security Number (SSN);
• The
clinical rationale for denial of payment for specific services (form
letters are unacceptable as the clinical rationale shall provide
a complete explanation, referencing any and all appropriate documentation,
for the cause of the denial);
• All applicable
appeal and grievance procedures; and
• The name
and telephone number of an individual from whom additional information
may be obtained.