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Managed Care 101: Utilization Management

Slide 1 Managed care 101: Utilization ManagementMelanie Lite MatthewsCEO, Physicians of Southwest WashingtonCAPG SymposiumOctober 27, 2016 Slide 2 Slide 2 Content Overview Background to importance of coordinated care Building the care is the future: Think Outcome Data supports Utilization Management What is Utilization Management ? Essentials of Utilization Management Population Health Advanced care Management Importance of Comprehensive Primary care and Primary care Medical Home Models? Payor Contracts and UM Silos of Concern and Importance: Pharmacy and Behavioral HealthSlide 3 Slide 3 MACRA: Demise of FFS and Volume Based Reimbursement for Medicare BeneficiariesMIPS and APM models all promote quality and cost MIPS criteria applied to 2017 services 0% based on cost of care 60% based on quality of care 15% based on clinical care improvement activities 25% based on advancing care information (formerly meaningful use )Impact: +/-4% adjustment to 2019 FFS, with winners and losers Alternative Payment Models Must be participant in designated APM model including accountability for quality and costImpact: 5% increase to 2019 FFS reimbursement all winners!

• Milliman Care Guidelines (MCG) Slide 16. Proactive Mechanics of UM • Administrative procedures • Procedures as determined by benefit plan and payor – Discharge planning (from both acute and long term care facilities) – Concurrent review planning – Pre-certification

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