Medical Management Guide, 2009, Version 3.0 - Tricare

More documents

Recommendations

Info

Page 10 Medical Management EssentialsVersion 3.0Medical Management GuideTRICARE AND OTHER BENEFIT PROGRAMSMTF Commanders are responsible for all healthcare provided or purchased within their catchment/market area. As such, they have direct control overappointment and referral services as well as overMM programs for their TRICARE Prime enrollees.The TRICARE healthcare program (http://tricare.mil) serves Active Duty Service members (ADSMs),National Guard and Reserve members, retirees,their families, survivors, and certain former spousesworldwide. TRICARE contracts augment MTFservices. Each MTF, Multi-Service Market Office(MSMO), and TRICARE Regional Office (TRO) mustwork with its regional contractor (see Workingwith Managed Care Support Contractors, laterin this section) to develop individual memoranda ofunderstanding (MOUs) that establish programs andactivities specific to that particular facility. Contractimplementation may vary based on how each facilityinterprets an MOU. For additional information onTRICARE, contact your local TRICARE Service Center(TSC) and/or Benefits Counseling and AssistanceCoordinator (BCAC).TRICARE offers special programs, including theExtended Care Health Option (ECHO), ContinuedHealth Care Benefits Program (CHCBP), andComputer/Electronic Accommodation Program(CAP). For more information, go to http://tricare.mil/mybenefit/home/overview/SpecialPrograms.Most beneficiaries will have TRICARE as theirprimary provider or payor. But MM staff, specificallyUM and CM personnel, also need to have a basicunderstanding of other programs beneficiaries maybe enrolled in, such as:• Medicare, Medicaid: http://www.cms.hhs.gov/• Supplemental Security Income (SSI):http://www.ssa.gov/ssi/• Social Security Disability Insurance (SSDI):http://www.ssa.gov/disability/• U.S. Family Health Plan: http://www.usfhp.com/• U.S. Department of Veterans Affairs (VA):http://www.va.gov/See Appendix C, Definitions; and Appendix D,Resources for more information.Working with Managed Care SupportContractorsThe United States are divided into three TRICAREregions. Each of the regions has a regionalcontractor that helps administer the TRICAREbenefit plan. This role is defined as the ManagedCare Support Contractor (MCSC). MCSCs provide avariety of functions, including:• Establishing TRICARE provider networks.• Operating TRICARE service centers.• Operating customer service call centers.• Providing administrative support, such asenrollment, care authorization, and claimsprocessing.• Communicating and distributing educationalinformation to beneficiaries and providers.MCSCs work with their TRO to manage the benefitat the local level, and receive overall guidance fromTMA headquarters (TRICARE Fact Sheets, TRICARERegional Contractors for the United States, 2006).(See also Appendix C, Definitions.)
Medical Management Guide Version 3.0Medical Management EssentialsPage 11The MHS necessitates close collaboration betweenMM staff located in the DCS, embodied by the MTF— an Active Duty setting; and the PCS, embodiedby the MCSC — in a civilian setting. Patientsbenefit when their healthcare services are smoothlycoordinated between the DCS and PCS. This “handoff,”or patient transition, is the act of transferringMM functions from one responsible entity toanother. Patients may frequently transition betweenthe MTF and the network, or between individualMTFs.By contract, the MCSC runs programs that managethe health care of individuals with high-costconditions or with specific diseases addressedby proven clinical management programs; thisresponsibility extends to providing MM servicesfor beneficiaries enrolled in ECHO. The MCSC alsoassumes responsibility for enrolled beneficiaries withcatastrophic, high-risk, high-cost situations whosecare occurs (or is projected to occur), in whole orin part, in the civilian sector. Program specificationsvary by region and are governed by specific MTFMOUs with the MCSC.THE LINK BETWEEN CLINICAL ANDBUSINESS OPERATIONSThe fundamental concepts in determiningappropriate MM measures within the MTFare a) integration with the Command’smeasures and b) alignment with the local MTF’sstrategic vision and business plan.Business planning “encompasses all strategic goalsand activities needed to ensure an organization’ssurvival and growth,” with the outcome of thebusiness planning cycle being “a consolidated MHSbusiness plan that serves as a primary input to theProspective Payment System (PPS).” In this regard,Tri-Service business plans provide “a commonframework across the MHS for improving andmeasuring performance” in the DCS (FY 2010-2012Navy Bureau of Medicine and Surgery [BUMED]Business Planning Supplemental Guidance,CD-ROM Resource MME-2).According to the DoD’s Defense Health Program(DHP) FY 2009 budget estimates, the DoD’s totalhealth costs more than doubled between 2001 and2006, from $19 billion to $38 billion — an increaserepresenting 8 percent of the DoD budget. Thisincrease was attributed to a combination of benefitenhancements, increased beneficiary use, stablecost shares, and high healthcare inflation. Thosecosts were projected through trend analysis to reach$64 billion, or 11.3 percent of the DoD budget, byFY 2015 (refer to CD-ROM Resource ES-2, DoDDefense Health Plan (DHP) 2009 Highlights).The business plan is the MTF’s roadmap for financialsuccess, but clinical operations, in collaborationwith Resource Management staff, are crucial indetermining that road map. It is therefore essentialfor clinical staff to actively engage in the businessplanning process. Their knowledge gives them theability to validate baseline historical data such asenrollment, outpatient/inpatient workload, and outpatient/inpatientutilization.The staff primarily involved in producing workload,documentation, and coding should be consultedwhen the MTF is determining a particulardepartment’s productivity targets or goals (e.g.,
Page 2 and 3: Instructions:When accessing this Gu
Page 6: Page viExecutive SummaryVersion 3.0
Page 9 and 10: Medical Management Guide Version 3.
Page 15: Medical Management Guide Version 3.
Page 20 and 21: Page Medical Management Essentials
Page 22: Page Medical Management Essentials
Page 25 and 26: Medical Management GuideVersion 3.0
Page 27: Medical Management GuideVersion 3.0
Page 39: Medical Management Guide Version 3.
Page 44 and 45: Page 26Utilization Management Versi
Page 66 and 67: Fig. 11 (cont.) - MTF Review and Ap
Page 72: Page 54Utilization Management Versi
Page 76 and 77: Page 58Case Management Version 3.0M
Page 78 and 79:
Page 60Case Management Version 3.0M
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 100Case Management Version 3.0
Page 123 and 124:
Medical Management GuideVersion 3.0
Page 125 and 126:
Page 127 and 128:
Page 129 and 130:
Page 131 and 132:
Page 133 and 134:
Page 135 and 136:
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 165 and 166:
Medical Management Guide Version 3.
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Page 195 and 196:
Page 197 and 198:
Page 199 and 200:
Page 201 and 202:
Page 203 and 204:
Page 205 and 206:
Page 207 and 208:
Page 209 and 210:
Page 211 and 212:
show all

Medical Management Guide, 2009, Version 3.0 - Tricare

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?