Medical Management/Quality Assurance/Utilization Review

Medical Management/Quality Assurance/Utilization Review Standards

The goal of the program is to ensure that members receive appropriate, cost-effective care rendered by high quality providers. This goal is achieved through continual monitoring of treatment plans, provider credentials and provider performance.

The program is a URAC certified utilization review program and utilizes InterQual criteria for procedure review.

Medical Management/Quality Assurance/Utilization Review Examples

• Moving an outpatient procedure to a physician’s office or free standing facility when clinically appropriate
• Outpatient surgery when feasible
• Alternative treatment services such as home care and home infusion therapy
• Relevance of health care services to the medical needs of the patient based on age and clinical diagnosis
• Services consistent with the clinical impression or working diagnosis
• Appropriateness of treatment frequency and demonstration of compliance with evaluation and management coding guidelines
• Use of other health care services consistent with the patient’s medical needs
• Use of appropriate CPT codes and guidelines for visits, consultations, and treatment of the condition described
• Detection of duplication of diagnostic procedures
• Determination of provider compliance with managed care requirements
• Performance of procedures in a manner consistent with FDA or other guidelines and community standards
• Utilization of resources commensurate with burden of illness

Peer Review

Reviews of provider behavior will be performed by similarly boarded physicians, including both BHN medical directors and external practitioners.