Toolbox of UM model policies, procedures and plans that 'work' with P & Ps for traditional, streamlined, open access and other cost-effective management strategies. Contact capitation and other variations of traditional capitation compensation strategies are detailed. Case management and quality management programs. Resources include utilization management program example format, contract analysis formats, numerous forms benchmarks, job descriptions, legal resources and case citations, links to authoritative national guideline resources, references and a glossary of managed care terms.

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Utilization Management and Capitation Strategies
Published on February 2009
Report Summary
Toolbox of UM model policies, procedures and plans that 'work' with P & Ps for traditional, streamlined, open access and other
cost-effective management strategies. Contact capitation and other variations of traditional capitation compensation strategies are
detailed. Case management and quality management programs. Resources include utilization management program example format,
contract analysis formats, numerous forms benchmarks, job descriptions, legal resources and case citations, links to authoritative
national guideline resources, references and a glossary of managed care terms.
Table of Content
Capitation Toolbox ' Introduction; Behavioral Health Services; Capitation fundamentals; Direct access to specialty care
(self-referral); Capitation Pros and Cons; Medical Loss Ratios; DRG payment systems; HMO Pools; Readiness Audit List; Levels of
risk in capitation; Adverse selection; Medical group/IPA responsibility; Sponsor Discounts; Contracting Issues; The capitation contract;
Physician and other ambulatory visits per year (average); Hospital Admission Rates and LOS ' All Payer; Capitated HMO contract,
Representative major financial pools;
Capitation expense allocations; Risk sharing arrangements (table); Flow of funds, algorithm ' representational example; Capitation
payment date issue in relation member enrollment; Hospital per diem rates/discharge timing considerations; Physician Encounter
benchmarks; Critical success factors for managed care organizations, checklist; Capitation rate example; Health Plan Operational
Metrics; Physician Encounter benchmarks; Specialty Physician Payment Systems; 'Per Case' or global package pricing strategies;
Contact capitation; Specialist capitation; example strategy/plan; Pay for Performance (P4P) programs; Ancillary provider contracts;
Medicare 'Fraud and Abuse' /Health care compliance; Medicare is targeting costly physicians
¨ Utilization/Resource Management Toolbox ' Introduction to Utilization Management; Guidelines; Effect of guidelines on care;
Medical necessity ' What is it'; Case Law Citations ' related to medical necessity; Length of Stay Guidelines/DNR orders; Unplanned
readmissions w/audit form; Tracking new federal regulations;
¨ Utilization/Resource Management Program; Program elements; Referrals within the medical group; Medical necessity; Outreach;
Communication concerning UM policies to patients and the public ' example; Program elements; Report requirements; Pharmacy
Management; Documentation requirements; Utilization Resource Management Department; Discharge delays;
Basic elements of an UM plan (refer to UM Plan model in addendum); Consultations vs. referrals; UM Department staff and staffing;
UM Committee; UM Policy and Procedures ' example for medical group/IPA/MSO; The Review Process; Assignment of Case
Numbers P&P;
¨ Benefit and eligibility determinations ' Identification card; Financial Responsibility Guarantee Form; Eligibility and Benefits
Verification ' P & P; Precertification/Certification Worksheet; Eligibility FAQs;
¨ Case or Care Management (CM) - Introduction; CM program savings; Hospital UR/Case Management ' functions; CM roles and
responsibilities; Primary Case Manager ' Role/Responsibilities; Hospital Case Manager ' Role/Responsibilities; Specialty Case
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Manager ' Role/Responsibilities; Specialty Case Management; P & P; Specific disease examples for case management services;
Criteria for Social Service/Counseling Management; SCM case closing; P & P; SCM discharge form example; Hospital Case Manager
UM Variance Reports, example list; Preadmission Review/Precertification or 'Precerts'; Hospital charges for non-covered services;
Preadmission case management screening tool;
Procedure for prospective review; Prior authorization check list form; Diagnostic referrals; Diagnostic radiology referral form;
Procedures for 'Patient Care Plan' form completion prior to review; Authorization Request Form; Request for Authorization - additional
mental health services; form; Request for Authorization to provide additional services; form; Physical Therapy note; Request for
continuation of services; form; Referral Authorization form; Review Worksheet form; Reviewer Communication Form to Requesting
Provider;
¨ Observation status for acute care - P & P;
¨ Review Process ' Role of the physician advisor, Concurrent and Retrospective; Concurrent review; policy & procedure;
Concurrent review, work sheet form; Concurrent review check list form; Authorization review work sheet form; Length of Stay and next
review date assignment; 'stickey' example; Specialty pre-admission authorization; Blended Specialist-Primary Care Physician for a
Qualifying Patient; Primary physician notification; P&P with form;
Retrospective review, policy; Inappropriate admission - change in status; Discharge planning; policy and procedure; Authorization of
special services; Periodic review of pre-authorization policies ' example; Specialty pre-admission authorization; Primary physician
notification; P & P with form; Authorization approval notification form; Authorization denial notification form; Outpatient surgical
authorizations; procedure; Complications following non-covered services, policy; Custodial care, definition; Audit for Access Time to
Specialty Care Following Primary Care Referral.
¨ Ambulatory Services Management - The Minnesota Medical Practice Model; Out-of-Pocket (OP) Patient Expenses; Outpatient
surgical authorizations, procedure; Podiatry Services;
¨ Referral Authorization Strategies ' 'Passthroughs' or 'Automatic' Approval or 'Direct Access' ' example list; Streamline referral
process; 'Open Access' + example P & P for Chemical Dependency; Delegation of UR function to selected physicians; Specialty
physician delegated procedure list, by specialty; Urology referral check list; Orthopedic referral checklist;
¨ Emergency Services; P & P; Alternative care or redirection of care; References and resources related to ER services; 'Out of
Area' Care; P & P; Procedure for 'out of Network' Arrangements for care; Letter/Contract to 'Out of Network' provider; Payments for
Emergency Services to Non-contracted Providers ' California Law
¨ Home Health Care; Home Health/Hospice Case Management, Policies/procedures; JCAHO Emergency Preparedness for Home
Care; Home Health/Hospice - Case Management; Homebound criteria; Common reasons for failure/lack of use of home health
services, Skilled Home Nursing Care; Home Nursing for Ventilator or C-PAP Patients;
Physician directed homebound program, Home visits by physicians following hospital discharge; Care Plan Oversight; Home health
care referrals, P & P, Termination of home health care services, Home Health Aides/Assistants; Caregivers; Home health infusion
services, Oxygen coverage guidelines, Home Safety Visit Checklist, Hospice; Eligibility Requirements; Hospice benefits; Hospice care
in a SNF; Karnofaky Performance Scale; Home Health Care for Psychiatric Services;
¨ Skilled care Services; Skilled Nursing Facility, payment issues; Levels of skilled care;
¨ Durable Medical Equipment ; P & P; DME form;
¨ Denials, Appeals, Redeterminations, Grievances ' Introduction; Insurance denials for alcohol-related emergency treatment;
Denial and Appeal Process, policies and procedures; Medicare + Choice and Medicare time frames for appeals; Work sheet for
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physician reviewer; Standard denial letters; Denial Letter to provider, example format; Denial Letter; commercial member format,
examples; Denial Letter; Medicare HMO member format; Denial letter, SNF benefits; Denial retraction letter format; Denial letter,
exhaustion of SNF benefit, commercial; Acknowledgment of receipt of notice, SNF benefits denial; Notice of non-coverage; fax sheet
example; Appeals process, policy and procedures; Appeals Committee; Complaints/grievance reporting vis a vis provider contracts;
Appeals Review Status Tracking Form; Grievance tracking; References & resources re: appeals, denials, grievances; Denial rate '
examples; Claims letter denying payment, non-covered services, to com. Member; Claims letter denying payment for non-covered
services, to provider; External Reviews;
¨ Discharge Planning - Discharge Planning; Policy & Procedure; Stratis Health (MN QIO) Discharge Planning Quality Resources Kit
(links); Notes
¨ Annual U/RM Work Plan ' Special Studies; Program Surveys; Radiology performance profile for medical groups; Tracking
Hospital and SNF Admissions; Statistical reports, hospital bed days and other benchmarks
¨ Algorithms ' Prospective and concurrent review; Preadmission evaluation; Electronic referral process; Ambulatory Care Referral
process; Alternative UM process; Automatic or pass-through procedures; External provider authorization process; Preadmission ER
Evaluation; Utilization/Case Management, Behavioral Health; UM Case Management; Med/Surg, OB & ICU; Ambulatory Care
Authorization process
¨ Integrated Quality Management/Improvement Strategies ' Building a foundation for Quality constructs; Where should a higher-risk
procedure be performed in a specific patient or population of patients'; Introduction to the QA/QM/QI Department; Integration of
Utilization/Quality Management Programs; QM/UM overlap examples; 'Pay for Performance' programs; QI/QM Clinical
Indicators/Performance Goals Standards list; Case Mix Adjustment for provider profiles; Hospital/SNF QA Screens; Provider
Sanctions and Fines: QI Committee; Fine Notification Form; QM staffing ratios
¨ Administrative/'Back Office' Strategies, Policies and Procedures ' Staffing ratios for a MSO; Case contracting;
Claims processing; Submission of encounter data and claims; Coordination of Benefits; Third party liability; IBNR;
Operational standards (List); Committees; New Technology Assessment, P & P; Medical Records ' Issues in managed care contracts;
Non-contracted or 'Out of Network' Claims;
Hospital care performance standards, Hospitalist/attending physicians; Physician management services, conference time/phone calls;
Primary physician selection; Sign Language Interpreter services; Sanctions and Fines ' Utilization Management, P & P; UM
Committee Meeting Attendance Requirements; Social Work Services; Quarterly Primary Physician Dinner Meeting Attendance
Requirement;
Balance sheet & Income Statement Ratios; Transitional Care Center policy; Transportation, medical; UR Organizations, fiduciary
responsibilities; Waiver of Co-payments ' P & P; Worker's Compensation; ERISA
¨ Education Strategies ' Education for Patients and Providers ' Why'''; Emergency care brochure; Authorization process brochure;
Speed up the authorization process by ...; The Big Secret; Hospitalist care ' explanatory brochure
¨ R/UM Staff Job Descriptions and Effectiveness Evaluations ' Medical Director or Chief Medical Officer; UM Physician
Advisors/Directors job descriptions; Clinical Director, UM; Managed Care Coordinator; UM; Coordinator (Nurse reviewer); Concurrent
review nurse coordinator; Care Coordinator/Case Manager; Managed Care Technician I and II; Pharmacy Benefit Manager;
UM Staff Training and job standards; UM Reviewer Evaluation, P & P; Assessment tool for UM staff; Utilization review, Inter-rater
Reliability Evaluation P & P; Audit Tool; Audit of UM Authorization and Denial Services with tools and forms; Audit - hospital 1 to 2 day
admission tool
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¨ References and resources ' an extensive section, alpha listed by topic
¨ Appendices ' Utilization Management Program model; UM financial data collection - example formats; Medical Policy/Medical
Management Committee; Inpatient Days Prior to a Surgical Procedure ' Policy; Payment denials for surgical errors; Surgical Length of
Stay 'Benchmarks' or Targets; Medical LOS examples ' refer to the following LOS by DRG table;
Managed Care Legal Resources on the Web; Medicare Advantage Special Needs Plans - eligibility; Medicare+Choice, synopsis of
medical management rules and regulations; Demographic cost factors, senior, by class; Key Contacts at CMS;
Hospital care 'length of stay' targets, by age range; Frequency by Diagnostic/Procedural Group, Acute Hospital Care, California HMO
data; Hospital Days, Physician Encounters and Ambulatory Visits; LOS targets by DRG; Claims management consultants - resources;
Health plan/Medicare/Medicaid guideline resource links; Glossary of Managed Care Terms
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