Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 32Utilization Management Version 3.0Medical Management GuideUM staff can also apply review criteria to assist theMTF in identifying areas for improvement within thesystem. For example:• If a group of admissions are reviewedretrospectively using McKesson ® InterQual ®evidence-based decision support criteria and alarge number do not meet admission criteria,further investigation is warranted to determineand resolve the underlying cause.• If a group of cases referred for specialty caredoes not meet Milliman Care Guidelines ® , atraining issue may exist indicating the need foradditional clinical education.In both instances cited above, the criteria orguidelines have been used to reveal potential areasfor improvement, but the admissions and referralswere not denied. (For more information, seeOutcome Measurement and Management, laterin this section.)Types of ReviewThe procedures for UR may be:• Prospective (before care is provided—preadmission)• Concurrent (while care is in process— hospitalization)• Retrospective (after care has been provided— discharge)Prospective review is designed to evaluate proposedtreatment, determine medical necessity, and assessthe appropriate level of care prior to the deliveryof services. When performing reviews, referralsto CM or DM target early intervention to improveoutcomes. Formal prospective review determinationsrequire timely attention. Prospective reviews are onlyvalid for 30 days. If treatment was authorized butnot initiated within the window, the review shouldbe repeated.The MTF’s plan for UR may include more focusedreviews in which it identifies a list of healthcareservices for which preauthorization and concurrentreview may be required. It is neither necessary norcost effective to perform a 100 percent review of allreferrals for medical necessity. Criteria for UR mayinclude, but are not limited to, services defined byany of the following characteristics:• Costly• Known to pose potential medical risks formembers• Known to produce variable outcomes• New or investigational• Often performed for cosmetic reasons• Overutilized• Utilized differently by various providersConcurrent review is designed to evaluate carewhile it is occurring to validate medical necessity,appropriateness, and quality of care. The revieweralso looks for delays in service or complications,assesses if tests are appropriate, or evaluates thestatus of discharge planning.Inpatient concurrent review consists of twocomponents:• Admission review is conducted within 24 hoursof admission or on the next business day toverify the appropriateness and medical necessityof the hospitalization. Documentation in themedical record should justify the admission andplan of care. Discharge planning must begin atthe time of admission to resolve potential issuesthat may delay timely discharge or prevent thebest patient outcome.
Medical Management GuideVersion 3.0Utilization ManagementPage 33• Continued stay review is conducted at regularintervals throughout hospitalization to assessthe need for continued inpatient treatment.Review is usually conducted at prescribed timeframes throughout hospitalization or with achange in the level of care or the addition ofprocedures. If the patient is staying longer thanoriginally anticipated, CM should be notified.Patient-specific discharge plans should identifythe need for follow-up (see also Section III,Case Management, Discharge Planning).(Refer to Section V, Medical Management Tools,for data information systems and analysis that arevital to successful MM measurement and integrationfor both clinical and business practices.)UM outcome measures are commonly divided intodaily, monthly, and quarterly summaries and trackedover specific time frames according to the processimprovement or business planning needs of thefacility. Fig. 9 provides examples of UM measures foroutpatient, ancillary, and inpatient services.Retrospective review is conducted after treatmentand/or services are completed. It may identifytargets for future prospective or concurrent review.Third-party payors may require retrospective reviewto verify that the care being billed was actuallyprovided.• This process utilizes specific data elements tomeasure outcomes, identify areas of concernthat may require implementation of a qualityimprovement project, and evaluate theeffectiveness of health care.Focused retrospective review concentrates on oneaspect of care, such as appropriateness of service.General retrospective review examines the entirespectrum of care including quality, utilization,coding, appropriateness, necessity, and so forth.Outcome Measurement and ManagementMeasuring UM outcomes involves data collectionand analysis, and appropriate reporting. This processis essential for a successful program, but it can bechallenging to understand and apply the availableinformation systems and resources used by the DoD.The TRICARE Management Activity (TMA)Population Health and Medical ManagementDivision (PHMMD) maintains a centralized, externalcontract to license and distribute specific criteria andguidelines to MTFs and TRICARE Regional Offices(TROs). The selected products are believed to bethe best choices for the MHS, although they are notthe only products available in the industry. Theseproducts include McKesson InterQual evidencebasedclinical decision support criteria, which covera broad spectrum of medical/surgical and behavioralhealth care; and Milliman Care Guidelines, whichaddress the ambulatory care arena.McKesson ® InterQual ® — http://www.mckesson.comMcKesson InterQual evidence-based clinicaldecision support criteria are sets of measurable,objective, clinical indicators reflecting the need forhospitalization and for diagnostic and therapeuticservices in both the medical/surgical and behavioralhealth arenas.
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Medical Management Guide, 2009, Version 3.0 - Tricare

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