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Utilization Management
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To make utilization decisions, the PHPSM Care Management Program uses the national Milliman and Robertson (M & R) Health Care Management Guidelines, and takes individual Member circumstances and the local participating network delivery system into account when determining the medical appropriateness of health care services.
On an annual basis, PHPSM’s Quality Improvement (QI) Program provides the opportunity for Practitioners/Providers with professional knowledge and clinical expertise to: give advice; comment on development and adoption of utilization management (UM) criteria; and provide feedback on the process for applying the criteria via QI committees such as Evidence Based Medicine Collaborative Committee and Care Management Quality Improvement (CCQI) committee.
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Practice Parameters
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Practice parameters are strategies for patient management, developed to assist health care professionals in clinical decision-making. Practice parameters include standards, guidelines, and other patient management strategies. PHPSM’s clinical guidelines for utilization management decisions include:
- Nationally recognized Health Care Management M & R Care Guidelines
- UnitedHealthCare “Knowledge Library” Guidelines
- PHPSM Clinical Practice Guidelines
- Evidence Based Medical Criteria (as appropriate)
PHPSM clinical staff applies the aforementioned criteria for "uncomplicated" patients, particularly for length of hospital stay. For patients with complications or for a delivery system with insufficient alternatives to inpatient care, the following criteria are considered for individual patients:
- Age
- Comorbidites
- Complications
- Progress of treatment
- Psychosocial situation
- Home environment (when applicable)
Additionally, the clinical staff considers the PHPSM delivery network characteristics for the specific patient need(s), such as:
- Alternative levels of care
- Benefit coverage for alternative levels of care
- Participating hospital’s ability to provide all the medically necessary services within the estimated length of stay
PHPSM does not specifically reward Practitioners/Providers for denying coverage or care nor does PHPSM provide financial incentive to medical decision makers to encourage decisions that result in appropriate services not being used.
Furthermore, to ensure that all PHPSM staff involved in the decision making process are applying the medical criteria consistently, PHPSM conducts annual inter-rater reliability audits. Additionally, a Practitioner/Provider may submit a request on behalf of a Member, to discuss or obtain a copy of clinical criteria used in the determination of denied services or an adverse determination by contacting the PHPSM Care Management Department at (517) 782-8238.
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