Utilization Management - HMSA Akamai Advantage®

The HMSA Akamai Advantage and utilization management (UM) program seeks to ensure that medically necessary care is provided in the most appropriate setting. This goal is accomplished through utilization monitoring, cost control when appropriate, identification of treatment delivery problems, and modification of provider resource consumption.

HMSA’s UM program is an innovative, continually adaptable system of integrated processes and tools including medical policies and payment determination criteria, focused medical reviews, and claims suspend analyses. This system is designed to identify opportunities for improvement in all settings and levels of care, focus review activities, and create interventions that bring measurable results while ensuring quality and value and maximizing efficiency for members, providers, and HMSA.

Purpose

The UM program:

• Monitors utilization trends and develops programs to manage variances.
• Identifies areas where policy development and provider education are needed and responds to those needs.
• Analyzes cost/benefit ratios of various UM activities.
• Provides appropriate health care decisions based on criteria or processes established by Medicare for HMSA Akamai Advantage Plans.
• Manages the continuum of care through outpatient, inpatient, and home settings.
• Promotes evidence-based medicine.
• Differentiates between specific services in terms of use, cost, and risk to recommend appropriate services to monitor or review.
• Recognizes variations in practice patterns, billings, and coding histories to recommend appropriate intervention(s).
• Reduces, when possible, physicians’ administrative activities and expense.
• Maximizes return on investment (ROI) and improves efficiency.
• Provides a continuous feedback loop to monitor and report results.
• Integrates utilization management with quality improvement, pharmacy management, and other activities.

The UM program has no financial incentives for physicians or care management targets that promote or discourage use of health care services.

Continuum of Care

HMSA’s Akamai Advantage and Population Management program manages utilization through preventing illness, ensuring quality and value in medical treatment, and providing individual case management for chronic or catastrophic illnesses. A focused medical care review process facilitates the management of resources immediately prior to and during the rendering of services to the patient. The review process enables specific UM interventions to be designed to appropriately influence provider behavior and promote the best health care practices.

The UM program ensures that continuity of care and management of resources are used in all settings throughout the continuum of care. Comprehensive Population Management interventions range from early detection services and screening tests, inpatient and outpatient care, to individual case management of chronic conditions by providing assistance through comprehensive coordination of care resources.

Focused Medical Review

The focused medical review (FMR) process enables HMSA Akamai Advantage to systematically focus on specific issues and problematic areas across all settings and levels of care. The process applies varying review intensities based on variations in practice patterns, adherence to medical policies or evidence-based medicine, or compliance with billing or coding standards. Clinical reviews may be conducted concurrently and/or retrospectively by nurse reviewers and medical directors and may also result in referrals for case management assessment as needed for potential catastrophic and/or complex cases. The goals of the FMR process are to:

• Improve provider compliance to policies and standards.
• Minimize administrative requirements to reduce provider burden and improve provider satisfaction.
• Appropriately manage benefit expense.

Concurrent review - Nurse reviewers receive hospital census and admission notices daily and use the notices to identify problematic diagnoses for concurrent review. Inpatient cases are monitored concurrently, with nurse reviewers working with hospital physicians and case managers through ongoing education and coordination to ensure that procedures and levels of care are appropriate and that discharge is planned in a timely manner so that continuity and quality of patient care are maintained. Hospitals and HMSA coordinate efforts to determine the most appropriate level of care and identify alternative care settings, if warranted.

Retrospective review - Retrospective reviews involve review of medical records after services have been rendered. Reviewers determine the medical appropriateness of a service as well as compliance with HMSA Akamai Advantage guidelines. Retrospective claims review addresses specific issues and problems identified through substantive variances in utilization.

Reconsiderations and appeals - HMSA Akamai Advantage members and/or their representatives are provided information on how to file an appeal, the types of appeal available, who can request an appeal, what information to include, and what to do if they disagree with an appeal decision. Akamai Advantage members have the right to request an expedited review for precertification or reconsideration of a pre-service denial.

Claims Suspend Analysis

Medical Management UM staff retrospectively reviews post-service, prepayment claims, based on established criteria, relevant clinical information (e.g., medical records, medical literature, consultation with treating physicians and board-certified physicians), resources, and clinical or coding knowledge. These reviews may be conducted in conjunction with health center medical directors, facilities, physicians, and/or case managers. They validate variances among providers identified through data analysis of provider practices, billing and coding patterns, as well as thorough review of provider compliance with best-practices and evidence-based medicine.

Revision History