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Overview. Focus of Care Management ProgramProcess for placementReferralsDurationCost SavingsParticipationQuestionsAnswers?. Focus. CMP identifies recipients who are using Medicaid inappropriatelyEmphasis on appropriate care ? not fraudContinuity of careFacilitates coordination of care a
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1. Alaska’s Care Management Program (Lock In) Sandra Ahlin
Manager, Care Management Program
August 2007
2. Overview
Focus of Care Management Program
Process for placement
Referrals
Duration
Cost Savings
Participation
Questions
Answers?
CMP identifies recipients who need help in managing their healthcare.
We are not looking a this from a purely punitive point of view.CMP identifies recipients who need help in managing their healthcare.
We are not looking a this from a purely punitive point of view.
3. Focus CMP identifies recipients who are using Medicaid inappropriately
Emphasis on appropriate care – not fraud
Continuity of care
Facilitates coordination of care and communication between physicians, pharmacies, the recipient and Medicaid.
Educate the providers and recipients on the merits of the program
4. Process Analysis
Phase I
Phase II
Placement
Fair Hearing
5. Analysis Data analysis of claims history
Exceptions
“during a period of not less than 3 consecutive months, uses a medical item or service with a frequency that exceeds two standard deviations from the arithmetic mean of the frequency of use of the medical item or service by recipients of medical assistance programs administered by the department who have used the medical item or service as shown in the department’s most recent statistical analysis of usage of that medical item or service”
6. What does that really mean? The recipient has used approximately 2-1/2 times the amount of their peers of any given service or services during at least one 3 month period of review.
Must have at least one exception
Rarely has only one exception
7. Phase I Review
8. Phase I
9. Phase I
10. Phase I
11. Phase II Review Phase II is a comprehensive evaluation of medical services paid by Medicaid that includes a review of medical records. Phase II is completed by a “Qualified Health Care Professional” as required by 7AAC 43.027. Phase II considers, but is not limited to the following:
Concurrent Care
Closely Adjoining Dates of Service/Same Dates of Service
Overlapping DEA Class 2-5 Rx, from multiple prescribers
Patterns of “omissions” and/or “misleading” PHI disclosed to providers
Non-compliance with patient agreements and/or pain contracts
Provider statements
12. Phase II example
14. Phase II cont.
15. Selection of Primary Care Providers
17. Notification to Providers Recipient name
Date of birth
ID number
Name of Primary Care Physician and/or Pharmacy
Start and end dates of program
Care Management specific information
Referrals
Emergencies
Covered services
22. Duration of Placement inCare Management Program Twelve months of Medical Assistance eligibility in Care Management Program
Nine Month review
Request Provider Statement
Review of medical services utilized while in CMP
Determination of status
Continue in program
End program after 3 remaining months
23. Provider Statement
24. Cost Savings
25. Participation 73 Recipients placed since April 2005
104 participating providers
4 clinics
5 Medical Groups
5 RHFQ
36 physicians
8 ANP
45 Pharmacies