Population Health Management

At a Glance

Welcome to the Premier Health Group Population Health Management Department. Our goal is to provide you with the support you need to most effectively care for your patients. To achieve this goal, Premier Health Group partners with Premier Health Plan to provide certain administrative services for our patients. This department is your resource for ensuring your patients get the most appropriate level of care, coordinating their care, and providing additional healthcare resources as needed. 

This department will, if applicable

  • Review and authorize certain procedures when deemed medically necessary. A list of these procedures can be found on the Medical Quick Reference Guide at www.premierhealthplan.org under “Provider Resources.”
  • Review and authorize out-of-network and out-of-area care, including transition of care and member transfers to out-of-network facilities
  • Offer Care Advising services through the Premier Health Plan’s Personal Approach to Health (PATH) programs for eligible membership
  • Administer member and provider surveys and assessments

    For questions and additional information, call Medical Management Prior Authorization at (855) 869-7140(855) 869-7140 Monday – Friday, 8:00 am to 5:00 pm, EST.

    Procedures Requiring Prior Authorization

    Premier Health Plan’s Utilization Management department carries out the review of select services to promote high-quality, cost-effective and medically appropriate care. Prior authorization is the process Premier Health Plan uses to review specific procedures, treatments and devices to determine coverage. 

    For a complete list of procedures that will require prior authorization, please access the Quick Reference Guide. If you would like a hard copy of the Quick Reference Guide mailed to you, please call Provider Relations at (937) 499-7441(937) 499-7441.

    Medical policies outlining items, services and procedures utilized for review of prior authorization requests are available online. Clinical criteria or the benefit provision on which the decision has been based, will be sent upon request. If a provider wishes to ask for a prior authorization or pre-determination review, a written request must be faxed to Prior Authorization at (855) 431-8762(855) 431-8762 or submit their request electronically by accessing Identifi Practice For additional information on this functionality, please see the Welcome and Key Contacts section of this manual.

    The provider must include the clinical documentation that will be considered in the approval or denial of the procedure. 

    If coverage is not approved, the provider may appeal the decision by following the appeal process that is described in the Provider Standards and Procedures section of this Provider Manual.

    How and When to Contact Medical Management

    Providers may contact the Medical Management department for questions, additional information or to request a review for prior authorization. Call (855) 869-7140(855) 869-7140, Monday – Friday, 8:00 am to 5:00 pm, EST. 

    Premier Health Group providers must contact the Medical Management department to:

    • Authorize coverage for services requiring prior authorization (as noted in the Medical Quick Reference Guide)
    • Notify the plan of a member’s inpatient admissions to acute care hospitals, skilled nursing facilities, rehabilitation facilities and long-term acute care centers. This enables Premier Health Plan to identify members’ special needs and coordinate their care. In some cases, clinical staff may help arrange care in an alternate setting.

    After business hours and on observed holidays, calls to the Medical Management department are forwarded for after-hours management, seven days a week, 24 hours a day. There is an option to speak to a licensed registered nurse and/or a licensed physician for expedited reviews.

    Utilization Management

    A Premier Health Plan Utilization Implementation Team develops and oversees the design and implementation of the utilization management program. The success of the program relies upon and is supported by providers in our network.

    Program Goals

    The following are the goals of the Utilization Management (UM) program:

    • Provide high quality, accessible and affordable healthcare services to our members through a qualified network of providers who are systematically selected and retained through the credentialing and performance appraisal process
    • Maintain a model that empowers providers to make medical decisions, supports a medical home model and enables providers to proactively manage health care
    • Coordinate preventive care, wellness efforts and chronic Care Advising to ensure efforts are focused on the member
    • Respect and value the confidentiality, safety and dignity of all members
    • Verify that the UM program is in compliance with, and responsive to, applicable requirements of federal and state regulators and appropriate accrediting bodies
    • Meet the guiding principles of the Triple Aim:
      • OUTCOME: improve the health of our members
      • SERVICE: enhance the member experience
      • EFFICIENCY: control the cost of health care
       

    Qualification and Training

    Appropriately licensed, qualified health professionals supervise the UM process and all medical necessity decisions. A physician or other appropriate healthcare professional with an unrestricted license performs all medical necessity denials of healthcare services offered under the plan’s benefits.

    Medical directors:

    The medical directors oversee every aspect of the UM program, including medical review. The medical directors drive the review of all medical necessity decisions, conduct medical necessity reviews when determination cannot be offered by UM staff, and conduct reviews in keeping with the state contract.

    Utilization Management review staff:

    The UM staff and their activities are an integral component of the UM department. They support activities across the continuum of care to affect optimal outcomes, achieve continuity of care, support appropriate services and manage care within the benefits of our members.

    As such, the primary function of the UM staff is to review and verify medical appropriateness and necessity for members whose needs are represented in the following categories:

    • Prospective review /prior authorization of services
    • Predetermination of services
    • Identify the need and identify out-of-network services
    • Facilitate transition of care
    • Concurrent review of continued stay or ongoing services 
    • Discharge planning
    • Referrals to case management, when appropriate
    • Retrospective (post-service) review of services

    The UM department prepares utilization reports on a regular basis to communicate information needed to improve how healthcare services are used.

    All utilization review decisions are based only on appropriateness of care, service, existence of coverage and the setting of the covered service. Please note:

    • We do not use financial incentives in conjunction with our UM program.
    • We do not reward providers who conduct utilization review for issuing denials of coverage or service.
    • We do not offer financial incentives to UM decision makers that encourage decisions resulting in underutilization.

    Practitioners may speak with a UM representative and/or physician regarding a specific UM determination by calling (855) 869-7140(855) 869-7140. UM representatives are available Monday — Friday from 8:00 am — 5:00 pm EST. 

    After business hours and on observed holidays, calls to the UM department are forwarded to after-hours management, seven days a week, 24 hours a day. There is an option to speak to a licensed registered nurse and/or a licensed physician for expedited reviews.

    Inter-rater Reliability

    At least annually, our clinical leadership assesses the consistency with which physicians and UM RN Care Advisors apply UM criteria in decision making. The assessment is performed as a periodic review using InterQual® assessment sets to ensure consistent use of criteria in clinical decision-making and consistency. 

    Please note, for a list of health plan related terms and definitions, please refer to the dictionary at the end of this section.

    Provider Access to Criteria and Other Pertinent Policies

    Each contracted provider will have access to this Provider Manual, a quick reference guide and comprehensive orientation containing critical information about how and when to interact with the health plan.

    Premier Health Group provides copies of UM criteria to practitioners upon request. To request a copy, please call Provider Services at (855) 514-3678(855) 514-3678. Criteria can be mailed, emailed, faxed or reviewed over the phone.

    Program Methods/Utilization Management Process

    The UM process encompasses the following program components: After-hours service, referrals, prior authorization, predetermination, concurrent review, ambulatory review, post-service review, discharge planning, and case management/complex case management and care coordination.

    All approved services must be medically necessary. The clinical decision process begins when a request for authorization of a service is received. Request types may include authorization of specialty services, skilled/rehab services, outpatient services, ancillary services, scheduled inpatient services and/or notification of emergent/urgent inpatient services. The process is complete when the requesting provider has been notified of the determination in writing.

    Concurrent Review

    Concurrent review is the review of a member’s chart during an active hospital stay when a need for an extended stay or additional healthcare services might be required in the course of treatment. Concurrent review is performed by an Inpatient Care Advisor (ICA) during the same timeframe that care is provided to the member.

    The inpatient concurrent review process begins with the UM staff, who will

    • Assess the clinical status of the member
    • Verify the need for continued hospitalization
    • Facilitate the implementation of the provider’s plan of care
    • Consider the need for a referral to Care Advising
    • Promote timeliness of care
    • Determine the appropriateness of treatment rendered
    • Determine the appropriateness of the level of care
    • Monitor the quality of care to verify that professional standards of care are met 

    Information assessed during the review includes

    • Clinical information to support the appropriateness and level of service proposed
    • Whether the diagnosis is the same or changed
    • Assessment of the clinical status of the member to determine special requirements to facilitate a safe discharge to another level of care
    • Additional days/service/procedures proposed
    • Reasons for extension

    If, at any time, services cease to meet the criteria, discharge criteria are met and/or alternative safe level of care options exist, the Utilization Manager will notify the facility to see if additional information is available to justify the continuation of services. If the medical necessity for the case cannot be determined, the case is referred to a medical director for review. The need for Care Advising or discharge planning services is assessed early after admission. Each concurrent review thereafter will meet the objective of planning for the most appropriate and cost-effective alternative to inpatient care. Potential quality of care issues will be promptly referred to the Complaints and Grievances department for investigation and resolution.

    Inpatient Discharge Planning

    Discharge planning is a method of coordinating care, controlling costs and minimizing the chance of readmission by arranging for the appropriate services upon discharge from the hospital. For members who have not fully recovered or who do not require the highly specialized and expensive services of acute hospital care, discharge planning assists the member in receiving the most timely, appropriate, safe and cost-effective discharge with additional healthcare services, such as home health care or appropriate placement in an extended care facility.

    Discharge planning should occur as early as possible in a member’s hospital stay. Prior to discharge, the Inpatient Care Advisor reviews the post-hospital needs of the member with the UM/UR staff of the hospital and arranges for follow-up/outpatient services. 

    Referral to Care Advising

    The Inpatient Care Advisor should assess the need for Care Advisor intervention by considering the criteria outlined in the Personal Approach to Health (PATH) programs.

    Post-Service (Retrospective) Reviews

    A retrospective review is offered on a case-by-case basis for medical necessity after the services have been provided to determine whether services were delivered as prescribed and were consistent with payment policies and procedures.

    Identification of Post-Service Review

    The medical review process begins by obtaining and reviewing clinical data/medical records or contacting the appropriate nurse and/or physician for clinical information. Instances in which a post-service decision may be required:

    • Out of area utilization
    • Unplanned discharge
    • Late notification when member remains hospitalized

    Obtaining Pertinent Information

    The medical review process begins when the review staff obtains and reviews applicable clinical information from the medical record, a hospital/utilization review nurse, the referring/attending physician or the member and/or the member’s family. 

    The utilization review staff obtains relevant information to:

    • Verify that the proposed service is a covered benefit under that member’s policy
    • Assess the medical necessity of care provided
    • Assess the appropriate level of care
    Adverse Benefit Determination

    A denial of services is also called an adverse benefit determination, or adverse decision. An adverse benefit determination means that an admission, availability of care, continued stay or other healthcare service has been reviewed and, based upon the information provided, the healthcare service does not meet the requirements for benefit payment under Premier’s policy, contract or agreement, and coverage is therefore denied, reduced or terminated. Failure to make a medical necessity determination and notification with the required timeframes may be considered an adverse benefit determination for the purposes of initiating an appeal. Adverse benefit determinations also include ending or discontinuing coverage that has a retroactive effect except when discontinuance is the result of a member’s failure to make timely payments toward coverage, or is initiated by the member or, if applicable, the Exchange. 

    Adverse benefit determinations will be communicated in writing to the member and/or the treating/attending provider. The notification shall be easily understandable and will include the specific reason/rationale for the determination, specific criteria and availability of the criteria used to make the decision, as well as, the availability, process and timeframes to appeal the decision.

    In addition, verbal notification of adverse benefit determination is provided to the treating provider (attending physician or primary care physician if the attending physician is unknown), and the facility or provider and advises that the admission did not meet medical necessity criteria via assessment. 

    Peer to Peer Review

    Medical directors utilize all available resources to assist in determining if the requested service is medically necessary. Medical directors apply medical policy, his/her clinical knowledge, judgment, expertise and criteria to each case, taking into account the specific needs of that member and product benefit design. If the case involves a procedure or service that is not within the scope of any of the medical directors’ education and training, a board-certified specialty physician who has expertise in that area of medicine is consulted.

    Peer to peer reviews, also known as “reconsiderations,” can be requested related to prospective determinations or concurrent review determinations where an admission, availability of care, continued stay or other healthcare service has been reviewed and does not meet the requirements for benefit payment and coverage is denied, reduced or terminated. Please request a reconsideration within two business days of receipt of the denial. Premier Health Plan will conduct the reconsideration within three business days of receipt. Based on the enrollee’s condition, the provider can request an expedited reconsideration. Members (or providers on behalf of the member with consent) can request an appeal if they are not satisfied with the outcome of the reconsideration. Please note that the reconsideration process is not a prerequisite to an appeal/internal review or external review of an adverse benefit determination. 

    NOTE: The process outlined in this section does not apply to Medicare members/products.

    Appeal of Utilization Management Decisions

    See the Provider Standards and Procedures  section for information regarding appeals. 

    Program Evaluation

    Regulatory Compliance and Process

    The UM program is evaluated on a minimum annual basis, and modifications are made as necessary. The program is evaluated by using:

    • The results of member satisfaction surveys and/or member complaint, grievance and appeal data
    • Provider complaint and provider satisfaction surveys
    • Relevant UM data
    • Provider profiling
    • Over and underutilization
    Over and Under Utilization

    Poor quality of care can be the result of either under- or overutilization of services. Monitoring underutilization is integral to the health management programs and to services that assess the current state of the member’s clinical condition, such as medication refills and routine testing. Overutilization is assessed in the ambulatory setting through a review and analysis of diagnostic, laboratory and pharmacy services, and in the inpatient setting through review of compliance with guidelines for admission and appropriateness of discharge planning. Occurrences of “never events” and hospital-acquired conditions are monitored and managed as a potential quality of care case. Results are trended for improvement opportunities.

    The evaluation covers all aspects of the UM program. Problems and/or concerns are identified, and recommendations for removing barriers to improvement are provided. The evaluation and recommendations are submitted to the EH UM Committee for review, action and follow-up. The final document is then submitted to the governing body for approval.

    Satisfaction with Utilization Management

    Annually, Premier Health Plan will evaluate both member and provider satisfaction with the UM process. Member satisfaction survey results and/or member/provider complaints and appeals that relate specifically to UM, provider satisfaction surveys with specific questions about the UM process and feedback from members/providers who have been involved in appeals related to UM are used in evaluating provider satisfaction with the UM process, and to help determine how UM services can further empower providers and members. When analysis of the information gathered indicates that there are areas of dissatisfaction, Premier Health Plan will develop action plans to improve on the areas of concern that may include staff retraining and member/provider education.

    Personal Approach to Health (PATH)

    The PATH model aims to improve people’s lives through a collaborative, multidisciplinary Care Advising approach. The goals of the PATH approach are to improve the quality of care, enhance the patient’s experience, and reduce the total cost of care by appropriately utilizing scarce medical resources. The Care Advising team consists of personnel including the chief medical officer/medical director leadership along with nurses, community health workers, social workers, clinical nutritionists and pharmacists. The Care Advising team works with PCPs, specialists and home care agencies among others to coordinate follow-up care and support adherence to provider-developed care and treatment plans.

    Here is a list of some programs available to eligible patients, though specific programs may only be applicable to certain members depending on plan choice:

    • Complex Care Advising 
    • Condition Care 
    • Transition Care 
    • Catastrophic Care 
    • Advanced Illness Care (Does not apply to Premier Health Dual Advantage)

    Premier Health Group may introduce additional Care Advising programs in the near future. Please check back for updates on additional programs available to patients.

    How can you Refer a Patient for Care Advising Programs?

    Providers may refer a patient for Care Advising programs by calling the Care Advising department at (866) 721-8623(866) 721-8623. Providers can ask questions about the programs by calling Provider Services at (855) 514-3678(855) 514-3678. Representatives are available from Monday – Friday, 8 am — 5 pm.

    Complex Care

    Sponsored by Premier Health Group, specially trained Care Advisors assist members with a variety of their social and medical needs. The goal of the program is to help prepare patients to eventually self-manage their own diagnosis by developing strong partnerships between them and their provider. Through a collaborative, multidisciplinary approach, Care Advisors hope to partner with providers in improving the quality of care delivered while decreasing utilization rates of unnecessary services and procedures. 

    The Complex Care program is a collaborative initiative that engages a multidisciplinary care team consisting of social workers, nutritionists, contracted providers and more. The program includes collaboration with acute care hospitals, nursing, social services, medical staff, pharmacy, ED and the Quality departments and is offered to patients who have been identified through claims data and/or referrals. 

    Program Goals

    • Improve care coordination for patients across care settings
    • Optimize chronic Care Advising
    • Educate patients about diagnoses and self-management
    • Implement care plans for high-risk members and members with complex care needs
    • Improve medication compliance
    • Address member/caregiver needs regarding adequate support and resources at home
    • Improve adherence to the hospital discharge care plan for patients discharged to home
    • Decrease avoidable utilization events (e.g., readmissions)

    Program Methods

    The Complex Care program focuses on impacting a complex member population with multiple chronic conditions and high rates of utilization of medical services. The Care Advising team includes a medical director along with nurse Care Advisors, social workers, clinical nutritionists and pharmacists. The team will provide physician office, telephonic, and when appropriate, in-home assessments and proactive interventions of members identified for Care Advising outreach. The team will work with the PCPs, specialists and home care agencies (including home hospice) to coordinate follow-up care and promote adherence to treatment plans

    How are members with complex needs identified? 

    • Members with complex needs are identified through a variety of sources, including
    • PCP/physician referral
    • Claims or encounter data related to use of services, types of providers seen and cost of care
    • Pharmacy data, when available
    • Hospital discharge data or information collected through UM processes, including precertification requests, concurrent reviews, prior authorization reviews and reviews of hospital admission and readmission data

    Members can also be referred to Complex Care through

    • Healthcare providers
    • UM staff
    • Member, family or other caregiver; self-referral
    • Ancillary providers, behavioral health providers or behavioral health managed care organizations, pharmacists, the Medication Therapy Management program, disability management programs, other internal departments, employer groups or staff from community agencies

    What services are provided? 

    The Care Advisor works with the member and his/her care team to best assist the member after assessing the member’s situation, intensity of needs for healthcare services, level of services needed, care coordination, education and support. When appropriate, a comprehensive care plan is developed in coordination with all members of the care team.

    Specific assistance offered:

    • Providing continuity of care plan and determines the assistance that is needed and uses a collaborative approach that identifies who will be included, such as family, practitioners, pharmacist or community-based services.
    • Identifying barriers to the member’s meeting goals or complying with the plan, which includes such factors as poor compliance to the treatment plan, lack of understanding, not ready to make a change, financial hardships, poor supports, transportation issues or fragmented care
    • Helping the member to develop a self-management plan that may include how he or she will monitor the disease, use a practitioner-provided symptom response plan, comply with prescribed medications and attend practitioner visits
    • Following the member’s progress against the care plan that was developed for the member, including progress toward overcoming identified barriers, any adjustments to the care plan and following the self-management plan
    • Coordinating care for multiple services, including inpatient, outpatient and ancillary services
    • Facilitating access to care
    • Establishing a safe and adequate support system through interactions with the member and/or applicable caregivers 
    • Evaluating the member’s cultural and linguistic needs, preferences or limitations
    • Evaluating the member’s caregiver resources that are in place to support him or her with appropriate care and decision making
    • Evaluating available benefits and associated financial burdens, as well as what may be needed to support the member’s treatment plan and identified needs
    • Developing a care plan that
      • Addresses the identified needs
      • Includes long and short-term goals
      • Establishes a time frame for re-evaluation
      • Identifies resources to be used and at what level of care 

    Condition Care Programs

    Condition Care programs are an important component of Premier Health Plan’s effort to improve members’ health by providing intensive Care Advising for members with specific chronic illnesses. These conditions include COPD, asthma, CAD, CHF, and diabetes. 

    The goals of the program are to improve the member’s clinical outcomes and quality of life. 

    The program is structured to 

    • Identify members with chronic conditions
    • Conduct outreach
    • Assess members’ needs
    • Develop a coordinated care action plan that is created with the members’ input
    • Monitor the members’ progress with that plan

    Various interventions are used, aimed at increasing the member’s knowledge of his or her condition and improving the ability to manage the disease. A specialized team, in collaboration with the member’s providers, works to accomplish these goals through member education, coordination of care and timely treatment.

    In addition, these programs provide help for members to manage their chronic illnesses through preventive practices and adherence to their treatment plans. Specific focus is given to closing gaps in care, both preventative and chronic disease-related. Health management programs also help form connections with community support groups and agencies.

    Transition Care Program

    The Transition Care program’s goal is to provide members with the tools necessary to get and stay well especially during the critical period after a hospital admission. The Transition Care program helps patients decrease their chances of returning for readmission to the hospital after they have been discharged.

    Identifying Participants

    Members will be identified for participation in the hospital transition program using health plan utilization management referrals, admission/discharge/transfer feeds or facility census reports. Members will be prioritized for outreach based on their clinical presentation/condition, recent utilization events and presence of targeted chronic conditions. Members who meet the specific criteria as high risk for readmission will be noted as high priority.

    Interventions of the Program

    Eligible members who have been prioritized for outreach will receive a personalized Transition Care Advisor who will work closely with each member and his or her care team (both inpatient and ambulatory). The Care Advisor’s main objectives are to 

    • Help to proactively identify members who are at high risk for readmission based on clinical, social and psychological/behavioral factors
    • Help to activate and educate the members on their conditions and potential pitfalls
    • Review the member’s discharge plan and identify potential barriers
    • Ensure appropriate post-discharge follow-up
    • Make sure that care is coordinated after discharge between primary care, specialists and others (e.g., home health, infusion)
    • When appropriate, conduct basic medication reconciliation sometimes in conjunction with clinical pharmacy services
    • Develop a post-discharge plan of care that includes contingency planning in case the member develops new or worsening symptoms 

    Catastrophic Care Program

    The focus of the Catastrophic Care program is to manage and support patients and caregivers in instances where a patient experiences a significant, potentially life changing diagnosis (i.e., closed head injury, malignant cancer, degenerative neurological diseases, etc). The primary goal of the Catastrophic Care program is 

    • Support the implementation of the patient’s specialist’s treatment plan to prevent readmissions
    • Reduce unnecessary ER visits
    • Manage the patient’s pain and remove barriers that may prevent the patient and his or her caregiver from adhering to the treatment plan 
    • Transition the patient to the least restrictive setting

    Multidisciplinary Team

    The Catastrophic Care program coordinates services for patients with catastrophic and intensive needs using a multidisciplinary care team led by the patient’s PCP and specialist and overseen by a primary Registered Nurse (RN) Care Advisor (CA). Our team based model focuses on optimizing the health of the patient utilizing the broad skills of the PCP, RN CA, Registered Dietitian CA, social worker CA and the pharmacist CA to develop and implement personalized care plans for each eligible, covered patient.

    The team focuses on the comprehensive needs of the patient and caregiver, incorporating the patient’s physical and behavioral health status, personal preferences, confidence level and current lifestyle risks. Psycho-social, cognitive and functional disabilities, transportation and economic barriers that may impede health and adherence to the treatment plan are also addressed. The care team then considers the patient’s health plan benefits, local community and government agency resources that may provide services to improve the health and well-being of the patient.

    Program Goals and Objectives:

    • Immediately identify catastrophic and highly intensive cases through the UM process, member self-referral, provider referral and medical and pharmacy claims
    • Facilitate safe care transitions
    • Honor the patient’s preferences for care
    • Partner with the patient, their caregiver and their primary and specialty care providers to develop a personalized plan of care in the least restrictive setting
    • Improve medication adherence
    • Address patient/caregiver needs re: adequate support and resources at home
    • Coordinate a comprehensive community-based and home healthcare network of services
    • Facilitate appropriate communication across the entire care team
    • Optimize chronic Care Advising and close relevant gaps in evidence-based care
    • Educate patients about diagnoses and self-management
    • Lower total medical expenses by avoiding readmissions, ER visits, duplicative and unwarranted services and specialist costs through coordinating care during acute, intensive care episodes.

    Advanced Illness Care (Does not apply to Premier Health Dual Advantage)

    The Advanced Illness Care (AIC) Program is an integrated and patient centric program that aims to enroll patients who are possibly in the last year of their life to support them/their caregivers with addressing their goals, values and preferences.

    Multidisciplinary Team  

    The patients in the AIC Program will be identified through a monthly stratification process, provider referral, and/or self-referral. Using a multi-disciplinary care advising team, led by an identified primary provider and overseen by a registered nurse care advisor (CA), the team will focus on the comprehensive needs of the patient and caregiver, incorporating the patient’s physical, religious/cultural and behavioral health status, personal preferences and confidence level, and current lifestyle risks.

    Program Goals and Objectives

    The objectives of the program are to:

    • Improve care coordination for patients in collaboration with their primary physician and specialist treating physicians
    • Optimize symptom management to improve quality of life
    • Support the physician’s treatment plan to stabilize the patient’s condition
    • Facilitate and coordinate transitioning the patient to the least restrictive setting
    • Implement personalized care plans
    • Improve medication compliance
    • Address patient/caregiver needs regarding adequate support and resources at home
    • Provide emotional support
    • Decrease “avoidable” utilization events (e.g., readmissions) and increase the number of patients engaged with Hospice

    Clinical and Preventive Health Care Guidelines

    Premier Health Group strongly endorses the value of clinical practice and preventive health guidelines and the Premier Health Group Quality Committee is responsible for the ongoing review of these guidelines. The Quality Committee assists Premier Health Plan with monitoring adherence to practice guidelines and identifying opportunities for improvement when non-adherence is identified. Premier Health Plan reviews all practice guidelines annually and updates them as needed to reflect changes in recent scientific evidence or technology.

    These guidelines include:

    • Adult cholesterol management
    • Attention deficit/hyperactivity disorder
    • Depression
    • Diabetes mellitus health management guidelines
    • Evaluation and management of heart failure—outpatient
    • Management of asthma in infants, young children and adults
    • Management of hypertension
    • Prenatal care guidelines

    If applicable, Premier Health Group will conduct annual reviews and updates of the clinical guidelines and pediatric (birth to age 19) and adult (ages 19 and older) preventive health guidelines. Providers are encouraged to follow these guidelines to reduce variation in care, prevent illness and improve members’ health. Please note, behavioral health services are provided by Optum and may undergo their own clinical guideline review. 

    For an updated list of clinical and preventive health guidelines visit PremierHealthPlan.org or call Provider Services at (855) 514-3678(855) 514-3678 for a hard copy. Provider Services representatives are available Monday – Friday from 8:00 am – 5:00 pm.

    Identification and Closure of Care Gaps

    Proactive Care

    The Proactive Care program is a multifaceted, coordinated strategy designed to support optimal performance on the quality measures linked to financial incentives in value-based contracts. The program utilizes analytic tools, integrated technology solutions and outreach support to leverage a variety of touch-points for care gap closure.

    Program Goals

    • Ensure optimal care for covered populations by identifying and closing gaps in care
    • Promote better coordinated care to prevent gaps from occurring
    • Achieve revenue goals through earning value-based bonus payments for quality 
    • Engage physicians, practice staff and patients in closing care gaps

    Identifying Care Gaps

    Patients with care gaps are identified using claims data (both medical and pharmacy), EMR data (when available), feedback from practices and feedback from Care Advisors. Physician practices are notified of care gaps through quarterly or bimonthly reports.

    Program Interventions

    In addition to the variety of interventions available to support the closure of specific gaps in care, a suite of reports provides the information and feedback that practices need to provide real time support. These reports help practices understand which gaps are most prevalent, identify if process redesign might be needed and support direct patient outreach.

    • Additional program components include
    • Care gaps are fully integrated into longitudinal Care Advising programs
    • Staff is trained on care gaps, how to close them and how to document in Identifi
    • For patients who don’t qualify for Care Advising, automated, integrated outreach is used to prompt office visits and enable follow-up by a live outreach specialist

    Member and Provider Surveys and Assessments

    Health Assessment Survey

    According to the Centers for Medicare and Medicaid Services (CMS) guidelines, Premier Health Plan performs a health assessment survey for all new Medicare Advantage members to determine their clinical risk for the development of chronic illness. This tool assesses the member’s clinical status and any psychological, emotional or environmental issues that may affect his or her health. This information assists in identifying high-risk members for enrollment in Care Advising programs.

    Member and Provider Satisfaction Surveys

    Premier Health Plan conducts annual surveys of both member and provider satisfaction. Participation by members and providers enables Premier Health Plan to develop quality improvement plans. The surveys assess

    • Access to care and/or services
    • Overall satisfaction with the Health Plan
    • Provider availability
    • Quality of care received
    • Responsiveness to administrative processes
    • Responsiveness to inquiries

    Provider Performance Tracking

    Premier Health Plan is continuously analyzing and identifying best practices and areas of improvement regarding quality of care and cost-effectiveness. Only providers with a predetermined minimum number of Premier Health Plan members may have clinical profiles developed. These individual profiles compare providers to the performance of all other providers within their specialty and against national benchmarks. The profiles may be distributed to providers on a semiannual basis.

    Quality Improvement Program

    The goal of the Quality Improvement program is to continually examine clinical and administrative operations in an effort to improve Premier Health Group’s ability to deliver high-quality, timely, safe and cost-effective healthcare services.

    The Quality Improvement program operates in accordance with the guidelines established by the National Committee for Quality Assurance (NCQA) and the Centers for Medicare & Medicaid Services (CMS).

    Through systematic review, the program critically assesses Premier Health Group’s performance regarding customer service, provider satisfaction, credentialing, pharmacy, preventive services, and utilization of resources and various healthcare initiatives with the use of provider performance data.

    At the center of the program are the providers who serve on the Quality Committee and Quality Improvement Committee (QIC). The Quality Committee and QIC, representing providers and administrative leadership, operate directly under the auspices of the board of directors. The QIC is vital to Premier Health Group because it develops and evaluates clinical and operational standards for providers.

    The Provider Agreement requires providers to comply with the Premier Health Group Quality Improvement Program including allowing the plan to use their performance data. To obtain additional information, providers may call Provider Services at (855) 514-3678(855) 514-3678, Monday – Friday, 8:00 am - 5:00 pm or Premier Health Group’s Quality Improvement Manager at (937) 499-9739(937) 499-9739.

    Health Plan Definitions

    Assigning Lengths of Stay – A process for assigning approved days for an acute care inpatient admission based on relevant clinical information.

    Business Day – means Monday — Friday, except for Federal holidays.

    CMU – case manager utilization 

    CSR – clinical services representative

    Covered Service – A healthcare service that is a covered benefit under the member’s benefit plan.

    Concurrent Review – A review during a course of treatment to determine whether the amount, duration and scope of the prescribed services (including extended stays or additional healthcare services) continue to be medically necessary or whether a different service or lesser level of service is medically necessary.

    Emergency Medical Condition – A medical condition that reveals itself by acute symptoms of sufficient severity or pain such that a prudent layperson could reasonably expect the lack of immediate medical attention to result in (a) placing the health of the person (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (b) serious damage to bodily functions or (c) serious dysfunction of any bodily organ or part.

    Identifi™ – An integrated health management system for documentation of information related to the member’s health, hospital confinements, ongoing monitoring, care, or case management, etc.

    InterQual® Criteria – A regularly updated, rules-based, patient specific evidence-based medicine decision support system that ensures medical necessity reviews are based on established clinical guidelines and criteria. InterQual® criteria can also be used to help determine initial length of hospital stay.

    Length of Stay (LOS) – The number of days between hospital admission and hospital discharge. The day of admission is counted; the day of discharge is not.

    LTAC – long term acute care facility.

    Minimal Data Set (MDS) – Clinical information needed for pre-authorization services.

    Medical Necessity – The services covered under Premier Health Plan that are decided to be all of the following:

    • Commonly known as appropriate for the diagnosis or treatment of the member’s condition, illness, disease or injury
    • Obtained from a provider
    • Given under standards of good medical practice and consistent with scientifically based guidelines of medical, research or healthcare coverage groups or agencies 
    • Reasonably expected to improve a person’s condition or level of functioning
    • In conformity, at the time of treatment, with Premier Health Plan’s medical management guidelines
    • Not exclusively provided as a convenience or comfort measure or to improve physical appearance
    • Done in the most cost-efficient manner and setting appropriate for the delivery of the health service
    • Not experimental/investigational
    • Not otherwise excluded by the member’s benefit plan

    Ongoing Ambulatory Care – Ambulatory care of symptomatic conditions usually requiring regular or frequent visits or encounters (e.g., allergy injections or therapy visits).

    Personal Approach to Health (PATH) – Premier Health Group’s holistic Care Advising approach.

    Participating or Network Provider – A facility, hospital, doctor or other healthcare professional that has been credentialed by and contracts with the self-insured employer-sponsored health plans that Premier Health Plan serves as a Private Review Agent.

    Prior Authorization (Pre-service Decisions) – A determination made by Premier Health Plan to approve or deny coverage for a provider’s request to provide a service or course of treatment of a specific duration and scope to a member prior to the provider’s initiation or continuation of the requested service. (May also be referred to as prospective review, pre-certification or organization determination.)

    Rehabilitation (Rehab) – For the purposes of this document, facility-based care that includes a wide array of services, including evaluation and treatment to help patients recover from an illness or injury or therapy for those with disabilities. Treatment teams evaluate individual needs and develop a rehabilitation plan to meet those needs with the focus being to help the member gain independence.

    Skilled Nursing Facility (SNF) – A type of healthcare facility recognized by the Medicare and Medicaid systems as meeting long-term healthcare needs for individuals who have the potential to function independently after a limited period of care. A multidisciplinary team guides healthcare and rehabilitative services, including skilled nursing care. Skilled nursing care includes rehabilitation and various medical and nursing procedures.

    Urgent Medical Condition – Any illness, injury or severe condition that under reasonable standards of medical practice would be diagnosed and treated within a 24 hour period and, if left untreated, could rapidly become a crisis or emergency medical condition. The terms also include situations where a person’s discharge from a hospital will be delayed until services are approved or a person’s ability to avoid hospitalization depends upon prompt approval of services.

    Utilization Management (UM) – An objective and systematic process for planning, organizing, directing and coordinating healthcare resources to provide medically necessary, timely and quality healthcare services in the most cost-effective manner.