Alaska s Care Management Program Lock In

1. Alaska�s Care Management Program (Lock In) Sandra Ahlin Manager, Care Management Program August 2007

2. Overview Focus of Care Management Program Process for placement Referrals Duration Cost Savings Participation Questions Answers? CMP identifies recipients who need help in managing their healthcare. We are not looking a this from a purely punitive point of view.CMP identifies recipients who need help in managing their healthcare. We are not looking a this from a purely punitive point of view.

3. 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

4. Process Analysis Phase I Phase II Placement Fair Hearing

5. 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 department�s most recent statistical analysis of usage of that medical item or service�

6. 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

7. Phase I Review

8. Phase I

9. Phase I

10. Phase I

11. 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

12. Phase II example

14. Phase II cont.

15. Selection of Primary Care Providers

17. 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

22. 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

23. Provider Statement

24. Cost Savings

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