Current through 2024-38, September 18, 2024
1.04-1 Identification of Members
A. The Program Integrity Unit will identify
members who appear to be obtaining health care services that are not medically
necessary. Members who are suspected of obtaining health care services that are
not medically necessary may be identified by the following sources:
1. Referrals or complaints from members,
providers, professional associations, health care professionals and other
citizens;
2. Referrals from the
Department of Health and Human Services ("DHHS"), Office of MaineCare Services,
Fraud Investigation and Recovery Unit, the Department of Attorney General,
Health Care Crimes Unit, third party payers, State of Maine Board of Pharmacy,
the Health and Human Services Office of Inspector General (OIG), Center for
Medicare and Medicaid Services (CMS), State and local law enforcement agencies,
and any other State or Federal agency;
3. Computer generated reports that identify
members who may be over-utilizing or inappropriately using health care
services.
B. Following
the identification of members who appear to utilize health care services that
are not medically necessary, the Program Integrity Unit may:
1. Analyze the computer-generated profiles of
the member's reimbursed health care services for the previous six (6) months,
or longer if indicated;
2. Review
the member's clinical records to document the medical necessity as well as the
frequency of services billed, and if necessary;
3. Communicate with the key providers to
determine if over-utilization is occurring.
C. Upon completion of the initial review
process, DHHS or its Authorized Agent may contact the member who appears to
have over-utilized health care services, to discuss the member's pattern of
utilization of health care services. During the contact, the DHHS or its
Authorized Agent shall review a summary of the member's primary care provider,
pharmacy and hospitalization or other service usage and the member shall be
given an opportunity to explain his or her utilization pattern. In addition to
explaining the Restriction Plans, DHHS or its Authorized Agent may also provide
information on how to obtain appropriate health care services or refer the
member to an appropriate agency to obtain services for an identified
problem.
D. DHHS or its Authorized
Agent shall make notes to document the content of the contact, member responses
and any referrals. DHHS or its Authorized Agent shall provide the member with a
contact name and office telephone number as resources.
E. DHHS or its Authorized Agent shall refer
the case to the Member Review Team for evaluation in cases where no apparent
medical necessity for the health care services exists and/or over-utilization
continues.
1.04-2 Member
Review Team - Case Evaluation
The Member Review Team shall review cases referred under
the preceding Section to evaluate the utilization and medical necessity of the
health care services rendered to members. The Member Review Team shall
summarize its findings and recommendations in writing. The Team may
recommend:
A. That the member be
monitored by DHHS or its Authorized Agent until more documentation and
information is available.
B. That
DHHS or its Authorized Agent contact the member to discuss, verbally or through
written communication, the member's health care utilization and concerns. The
DHHS or its Authorized Agent will inform the member of the benefits of proper
health care utilization and assist the member, if necessary, in securing a
health care provider. The Unit representative will also explain the Restriction
Plans that could be implemented should the current pattern of utilization
continue
C. That the member be
enrolled in one or more of the four types of Lock-In of the Restriction Plan
for restriction to a health care provider, pharmacy, hospital and/or other
provider as necessary in order to improve the member's health care benefits
usage. The Team may recommend an initial enrollment in the Restriction Plan for
a period not to exceed twenty-four (24) months. Subsequent re-enrollment
periods, if necessary, are limited to twelve (12) month
periods.
1.04-3 Member
Review Team -Plan Criteria
A. Restriction Plan
Criteria
The Team may elect to enroll the member into the
Restriction Plan if the member has exceeded medically necessary utilization of
medical services or benefits. The Team determines over-utilization on a
case-by-case basis that includes an evaluation of the member's medical
condition and need for services as determined using relevant information
including but not limited to the medical record, claims data and national
standards for best practices. The member must retain reasonable access to
MaineCare services of adequate quality, including consideration for geographic
location and reasonable travel time.
1.04-4 Member Notification
If the Member Review Team's decision is to enroll the
member in the Restriction Plan, the Program Integrity Unit shall mail a Notice
of Decision to the member and provide the member with:
1. The Team's decision,
2. A summary of the evidence upon which the
Team's decision was based,
3. The
effective date of the restriction and/or enrollment into the Plan,
4. Citation of the rules supporting the
Team's decision,
5. A health care
provider and/or prescriber designation form, and
6. Notice of the member's right to request an
administrative hearing and appeal the Team's determination in accordance with
the Maine Medical Assistance Manual, Chapter I, and Chapter IV.
B. The member shall have thirty (30) days
from the receipt of the Notice of Decision to complete the health care provider
and/or prescriber designation form and return it to the Team. If the member
fails to return the completed health care provider and/or prescriber
designation form or otherwise notify the Program Integrity Unit of his/her
designation of health care providers and/or prescriber, staff of the Program
Integrity Unit shall select the member's health care providers and/or
prescriber based on the member's medical needs and geographic location.
C. Selection of the health care
provider(s) and/or prescriber by the Program Integrity Unit staff or through
oral notice by the member shall be so documented in the member's file.
Enrollment in the Restriction Plan shall not begin until after the member has
had an opportunity for an administrative hearing, if requested. If a hearing is
not requested by the member within thirty (30) days of the date of the Notice
of Decision, then the member's enrollment in the Restriction Plan shall become
effective immediately upon confirmation with the participating health care
providers.
1.04-5
Provider Notification
The Program Integrity Unit will contact by telephone each
health care provider and/or prescriber selected, to explain the Restriction
Plan and solicit the provider's participation and cooperation. If the provider
agrees to participate as the health care provider and/or prescriber for the
member, a follow-up letter shall be sent by the Program Integrity Unit to the
provider confirming his/her participation and the date on which the restriction
shall begin.
