Partnering for effective medical case management

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Partnering for effective medical case management
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What is utilization review, utilization
management?

• Utilization review (UR) involves comparing
  treatment requests for medical services to
  treatment guidelines. Utilization management (UM)
  is the ongoing process of assessing, planning,
  organizing, directing, coordinating and
  evaluating health-care services.

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What is case management?

• Case management is a collaborative process that
  assesses, plans, implements, coordinates,
  monitors and evaluates the options/services
  required to meet the client's health and human
  services needs. It is characterized by advocacy,
  communication and resource management it
  promotes quality and cost-effective interventions
  and outcomes.

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MCO treatment authorization process (C-9)

• C-9 or treatment request
• Must be legible
• Proper identification of treatment
• Frequency/duration
• Identification of body part
• Appropriate requesting provider

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MCO treatment authorization process (C-9)

• Review claim allowances vs. hearing orders
• Initiate clarification process
• Review history of approvals and denials
• Contact with parties (when warranted)
• Determine necessity for independent medical exam
  (staff with BWC)

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UR/UM and case management

• Minimal UR/UM requirements include
• Inpatient services
• Outpatient services (including surgery)
• High cost diagnostics/treatment/services
• Physical medicine modalities.

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UR/UM and case management

• Medical case management
• MCO provides medical case-management services
  based on
• Severity of claim (including obtaining a
  treatment plan)
• Reviewing plan with treatment guidelines
• Authorizing medical services/supplies
• On-site visits
• Life care planning, etc.

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UR/UM and case management

• Initial review and/or peer review necessary
• Quality assurance
• Should have a medical management program that
• Is updated quarterly
• Coincides with URAC standards
• Maintains a credentialing committee for panel
  providers and a quality assurance committee for
  panel and non-panel providers.

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UR/UM and case management

• Treatment standards and guidelines to follow
  include
• Official Disability Guidelines (ODG)
• Mercy
• Milliman Robertson (MR)
• Others are also available and used.

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Case managements role in medically managing
claims

• Assists with coordination/collaboration of care
• Acts as injured worker advocate
• Assists with decision making
• Educates involved parties
• Enhances case/claim resolution
• It is effective when case management is offered
  in a climate that allows direct communication.

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Claims requiring case-management intervention

• Mandatory medical case-management assignment
• All lost-time claims with a disability period of
  21 calendar days or greater with lost time
  continuing
• All catastrophic claims
• Amputations
• Brain injuries (traumatic or anoxic)
• Spinal cord injuries

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Claims requiring case-management intervention

• Eye injuries requiring hospitalization
• All claims with request for inpatient
  hospitalization
• All claims with psychiatric disorders allowed
  requiring hospitalization
• Claims with pre-existing or non-related
  significant co-morbidities, such as diabetes,
  heart disease, mental health disorders, etc.
  which negatively impact the disability duration

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Case management

• Case assessment
• Has the injured worker been provided education
  regarding the specific work-related injury and
  proposed plan of treatment?
• Is the injured worker compliant with the current
  treatment plan?
• What is the injury prognosis and expected
  duration of disability?

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Case management

• Case assessment continued
• What are possible obstacles to return to work?
• Education
• Motivation
• Employer participation
• Provider participation
• Other factors (i.e., pre-existing medical
  conditions affecting injury resolution, etc.)

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Case management

• Case-management components and requirements
  include
• Implementation according to establish URAC
  standards
• Development in collaboration with the clients and
  members of the health-care team
• Set expectations.

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Case management

• Identifies short-term, long-term goals (URAC)
• Time frames to response to referrals
• Follow up and evaluation
• Resources to be used
• Collaborative approaches to be used
• Determine if return to work is feasible
• Documentation in case-management notes

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Identify Senate Bill 7 (SB 7) provision
requirements for ADR

• SB 7 states BWC can adopt a rule to specify that
  the resolution procedures shall not be used to
  resolve disputes concerning medical services
  rendered that have been approved through standard
  treatment guidelines, pathways or presumptive
  authorization guidelines. BWC is pursuing a rule
  change to implement and will notify providers
  when it takes effect.

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SB 7 provision and ADR process

• Responsibilities of the MCOs include
• Identifying the specific treatment guidelines
  used
• Supporting criteria for the approval.

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ADR process and case management

• Peer reviews/IMEs
• MCO responsible for ongoing education of peer
  reviewers
• Make sure they adhere to BWCs guidelines,
  including
• Quality of reports
• Miller
• Reference to guidelines
• Legible report
• Include all diagnosis (allowed/disallowed).

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ADR and case management

• Disputes are on the rise due to
• Lack of case direction
• Lack of collaboration
• Lack of education with parties
• Frivolous and/or repeated appeals
• Retroactive treatment requests.

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ADR and case management

• Noncompliance issues include
• Lack of an MCO established case-management plan
  affecting case direction and/or resolution
• Submission of retroactive treatment requests
• Noncompliance with submission of medical
  documentation from the treating or requesting
  physician.

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Questions?

• Contact information
• Alicia Vivo [phone]
• E-mail Alicia.v.1_at_bwc.state.oh.us
• Steve Taylor [phone]
• E-mail Steven.T.2_at_bwc.state.oh.us
• Web site ohiobwc.com