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 examine 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 to 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 cross-referencing
with
another 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 all
providers’ 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’s
business address). 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 other entities or reviewers identifty 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 at
least 20 cases per quarter from the quarterly list.
Providers associated with beneficiaries identified in the Beneficiary
PMP shall be prioritized for review.
Contractor Unless
directed by DHA, the 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 respond 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
’s
outcome, 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
Market/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 it available
to their network providers. These physician portals shall be
compliant comply with Health
Insurance Portability and Accountability Act (HIPAA) Privacy standards,
HIPAA Electronic Transaction standards, and any other applicable
Federal regulations.