Medical Management Guide, 2009, Version 3.0 - Tricare

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.