Medical Management Overview
The Medical Management Program is designed to monitor the appropriateness of all medically necessary and covered services for prior authorization care, concurrent review, and post-service care delivered to WPS customers.
The program has been developed in collaboration with WPS contracted health care providers and the WPS Medical Management team. Promoting optimal practice, while being sensitive to the current structure of the local delivery systems, is the strategy of our Medical Management Program. All components of the program comply with federal and state regulations. The program is designed to make utilization decisions affecting the health care of customers in a fair, impartial and consistent manner. The main goal of the Medical Management Program is to oversee and ensure the quality of relevant care while promoting appropriate utilization of medical services and plan resources.
The objectives of the Medical Management Program
Provide a structured process to continually monitor and evaluate the delivery of health care and services to our customers by:
- Establishing system-wide health management processes across the continuum of care.
- Establishing a process for provider feedback regarding utilization.
- Monitoring indicators to detect possible under- and over-utilization.
- Periodic auditing of denial decision timeliness.
- Conducting inter-reviewer reliability audits of all Case Managers and the Medical Director.
Improve clinical outcomes by:
- System-wide collaboration to identify, develop, and implement clinical practice guidelines and programs, which address key health care needs of the customers.
- Implementation of clear, consistent Medical Management requirements and key indicators of success.
- Implementation of Behavioral Health management processes.
- Development of mechanisms to measure and implement actions to improve under- and over-utilization.
- Collaboration with the Quality Improvement Committee/department to assess and implement actions to improve continuity and coordination of care.
Improve customer satisfaction by:
- Assessing customer satisfaction with Medical Management policies and procedures.
- Promoting appropriate utilization of WPS Health Plan resources through efficiency of service.
Meet or exceed established quality standards by:
- Complying with NCQA standards for the accreditation of Managed Care Organizations.
- Measuring program performance in accordance with the Health Employer Data Information Set (HEDIS) specifications.
The scope of the Medical Management Program consists of the following components:
- Primary care model of care
- Prior authorization determination of medical services
- Concurrent review decisions
- Post-service decision determinations
- Case management program
- Behavioral health management program
- Pharmacy management program
- Emergency services
- Technology assessment
- Affirmative Statement on Incentives (see below)
- Grievances and appeals
The Medical Management Program is supported by the following resources/tools:
- Nationally published and locally developed Utilization Management Criteria
- Clinical practice guidelines
- Policies and procedures
- Clinical experts
- External review
- Definitions from the Certificate of Coverage
Affirmative Statement on Incentives
Utilization Management (UM) decision-making is based only on appropriateness of care and service and existence of coverage. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision-makers do not encourage decisions that result in underutilization.