Alaskas Care Management Program Lock In

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Alaskas Care Management Program (Lock In)
Alaska

• Sandra Ahlin
• Manager, Care Management Program
• August 2007

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Overview

• Focus of Care Management Program
• Process for placement
• Referrals
• Duration
• Cost Savings
• Participation
• Questions
• Answers?

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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

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Process

• Analysis
• Phase I
• Phase II
• Placement
• Fair Hearing

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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 departments most recent
  statistical analysis of usage of that medical
  item or service

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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

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Phase I Review
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Phase I
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Phase I
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Phase I
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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

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Phase II example
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Phase II cont.
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Selection of Primary Care Providers

• A Care Management Program Coordinator selects and
  contacts a physician and pharmacy appropriate for
  recipient.
• Positive reaction from providers within the last
  two years.
• Education of providers
• Staff facilitates communication between provider
  and recipient which results in compliance.
• IHS beneficiaries

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Selection of Primary Care Providers

• Once the provider agrees to accept a specific
  Care Management recipient, that provider will
  become the only provider that the recipient can
  see without a referral

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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

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Notice of Care Management to Recipient

• Recipients are sent a notice that includes the
  following
• Start date of their participation in the Care
  Management Program
• Reason for placement in this program
• Primary Care Provider and Pharmacy
• Care Management specific information
• Referrals
• Emergencies
• Additional coupons
• Change of providers
• Fair Hearing Rights
• Phase I and Phase II Reviews

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Provider Groups

• Individual providers within a group need to be
  actively enrolled with Alaska Medical Assistance.
• Groups are allowed to act as the Primary Care
  Providers when a single medical record is used
  within that group practice.

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Referring to another Provider

• Primary Care Provider determines if recipient
  needs to be seen by another provider/specialist
• Medical need is determined by the Primary Care
  Provider, NOT the recipient
• Dates of service
• Single visit
• Specific amount of time
• Full year
• Hard copy
• Given to recipient
• Fax to referred provider and assigned pharmacy

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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

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Provider Statement
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Cost Savings
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Participation

• 73 Recipients placed since April 2005
• 104 participating providers
• 4 clinics
• 5 Medical Groups
• 5 RHFQ
• 36 physicians
• 8 ANP
• 45 Pharmacies