Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 30Utilization Management Version 3.0Medical Management GuideUM strategies may include a wide range ofinterventions to:• Target gaps in healthcare delivery.• Enhance performance and quality of care.• Assist in managing resources and improving thehealth of patients.• Refer patients who might benefit from otherprograms, such as CM and DM.How you determine the most appropriate typeof intervention will depend on the needs of thepopulation; the MTF’s capabilities, resources, andgoals; and available metric data. Consider incorporatingvarious UM strategies as well as otherMTF programs (e.g., Population Health, InformationManagement, or Resource Management) into theaction plan.Implement the action plan by performing theinterventions identified. Staff members responsiblefor implementing parts of the plan must:• Document their actions and any issues,obstacles, lessons learned, etc. Thisdocumentation will serve as formal feedback forfuture reference and help establish continuity inprocess improvement.• Report that information to the appropriatesupervisor.5. Determine the Effectiveness of theCorrective ActionStep 5 is the crucial step of determining howeffective you have been in implementing a correctiveaction. This step includes refreshing data elementsat consistent and regular intervals. It is essential toevaluate the impact of the actions taken so you candetermine whether the UM program was successful.Compare the action(s) taken to the outcome goalsand measures. Were there other unknown or newfactors that allowed for successful implementation?If the desired result or outcome was not achieved,then refine, adjust, or re-implement the strategiesand re-measure after an appropriate interval. Repeatthis step until the desired outcome is achievedwithout undesirable or unintended consequences.6. Make Additional Attempts to Fix theProblem(s)Step 6 is to continue to address any outstandingissues by periodically monitoring the measures.This will help you sustain any change or processimprovement through successive generations ofstaff and/or organizational structure, once you haveachieved desired outcomes.7. Learn from the Quality Improvement ProcessStep 7 is to ensure you have learned from the QIactivity by evaluating outcomes. This step helps youdetermine whether you have achieved your goalsand makes it easier to update the UM program, ifneeded. If goals have not been achieved, identifyimpediments (e.g., limited resources, poor training,ineffective communication). Discuss and validatefindings, formulate with the process owners aplan to address those findings, and communicatethe results of that evaluation to the involveddepartments and MTF leadership through theappropriate channels.When updating the UM plan, make sure it continuesto reflect current goals and mission needs. If
Medical Management GuideVersion 3.0Utilization ManagementPage 31applicable, redefine UM priorities and begin anew performance improvement cycle. Considerincorporating the strategy that resulted in successfuloutcomes into a written MTF policy that formallyincorporates prolonged sustainment of thoseimprovements as “routine business.”Review criteria may be employed as a screening toolduring the first level of UR when:a) The purpose is to manage resource utilization.b) There is a potential to deny payment for servicesthat are not medically necessary or that do notrepresent the most appropriate level of care.This QI process format is not mandatory. MTF staffmay use whichever format best meets their needs,but they should include all of the steps described inthe QI process when conducting UM. The range ofgoals and priorities will vary by MTF.As noted in Step 2, while MM staff are not alwaysrequired to act as data miners themselves, they areresponsible for assisting data analysts by identifyingissues, asking appropriate questions, and selectingthe relevant data elements when querying variousdata marts.Utilization ReviewUtilization Review (UR) as a component of UM isintegral to the success of both the MTF’s MM andbusiness plans. UR is the process of determiningwhether all aspects of a patient’s care, at everylevel, are medically necessary and appropriatelydelivered (McKesson, 2009). It is systematic becausethere is a prescribed sequence in applying thecriteria and in further reviewing the case if criteriaare not met. It is criteria-based because factorsbased on sound clinical principles and processes areapplied objectively in the first step of the evaluationprocess.Care is never denied for failure to meet criteria.Failure to meet criteria is only an alert that the caserequires further examination by a physician or otherqualified second-level reviewer.UM staff perform UR to ensure patients receive theright care, at the right time, in the right place, withthe right provider, and at the right cost. Withoutproper UR, the cost of health care, particularlyspecialty care referred inappropriately to the PCS,will spiral out of control. There is an absolutecorrelation between specialty care referrals (e.g.,RM) and business planning processes. (See alsoSection I, Medical Management Essentials,and Section V, Medical Management Tools,for more information on business planning andbusiness plans.)All healthcare services for which payment is soughtshould undergo review for appropriateness ofutilization. UM staff should work with business orpatient administrative personnel to set up a processin which third-party (insurance) payors are givenpriority consideration. For example, third-partypayors may require completed prospective reviewsfrom the MTF for surgery (e.g., hysterectomy, gastricbypass) before they will provide authorization andreimbursement for a surgical procedure performedwithin the MTF.
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