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.