UTILIZATION MANAGEMENT TECHNIQUES FOR PHYSICIAN'S SERVICES AND NONPHYSICIAN AMBULATORY SERVICES

THE OBJECTIVE OF THIS PROJECT IS TO PREPARE A PRACTICAL GUIDEBOOK THAT IDENTIFIES AND ASSESSES THE PERFORMANCE OF PRIVATE SECTOR PROGRAMS TO CONTAIN COST AND REDUCE EXCESS UTILIZATION OF PHYSICIAN AND AMBULATORY SERVICES. THE FOCUSWILL BE ON PROGRAMS THAT ARE PARTICULARLY SUITED TO MEDICAREAND ITS UTILIZATION EXPERIENCE. THE PROGRAMS EXAMINED WILL INCLUDE: DATA SYSTEMS USED TO IDENTIFY FOR FURTHER REVIEW PROVIDERS AND BENEFICIARIES WITH EVIDENCE OF EXCESSIVE OR INAPPROPRIATE UTILIZATION; SOFTWARE PROGRAMS THAT IDENTIFY INAPPROPRIATE PROCEDURE CODING AND PROVIDE THE APPROPRIATE CODING; PREPAYMENT AND RETROSPECTIVE CLAIMS REVIEW PROGRAMS; AND MANAGEMENT APPROACHES TO IMPROVE PROVIDER UTILIZATION PATTERNS, INCLUDING PROVIDER EDUCATION, PRECERTIFICATION PROGRAMS, ANDPROVIDER INCENTIVE PROGRAMS. THE PHASE I PRODUCT WILL BE A GUIDEBOOK IN THE FORM OF A BEST PRACTICES GUIDE, WHICH FOCUSES ON PROGRAMS THAT HAVE DEMONSTRATED A CAPABILITY TO REDUCE INAPPROPRIATE UTILIZATION. DURING PHASE II, MORE FORMAL EVALUATIONS WILL BE CONDUCTED OF THE UTILIZATION MANAGEMENT PROGRAMS IDENTIFIED IN THE GUIDEBOOK, FOCUSING ON DEMONSTRATED COST EFFECTIVENESS AND SUITABILITY OF SPECIFIC APPROACHES OF SPECIFIC PROGRAM TYPES AND PROVIDER ENVIRONMENTS.