This is ts advise you that we have completed a survey of States ’ eati” i- zation review (also ca3 led utf “aization control ) programs for non-institutional semi ces under Medi cai d e Such Frograms focus on services provided by phy- sicians ) dentists ) pharmacl’es 4 and other practitioners and are f ntended to assure that medical services i;rwided under Medicaid are necessary and appra- priate as well as to contro’l %l~caid costs by minimizing, and denying pay- ment for, unnecessary and i nap?ropriate services m We surveyed through a questionnaire the procedures used by States to control the util-ization 0-f noninstitutional services iincludl’ng:: --edits and checks in the States ’ cl aims processing systems ) including~ exception criteria used to identify possibly unnecessary services; * --practices used to deterza’ne if claims identified as being possibly unnecessary were in fact unnecessary; --the types of services subjected to review for appropriateness of care and the methods used to check. for appropriateness; --the number of personnel ass-i gned to determine necessity of care and the number assigned to check appropriateness of care (also call ed qua1 s”ty of care revierljs) ; --thg types of information the States” claims processiflg system is capable of producing, anr! does produce2 to assist the utilization candrol program; and --the results SF the utilization cowtrol program. c The survey showed (I) there was considerable variations among the States regarding the extent and emphasis of their program, and (2) about 70 percent of the States could not provide any quantifiable information on the restilk of their program in terms of claims denied. BACKGRQWNEB Over the last several years, HEW has been taking some actions, in response do the utilization control provisions of the Social Security Amend- ments of 1972 (P.L. 92-603), IX increase the effectiveness of the States utilization control over institutionaS services--those provfded in hospitals and skil'8ed nursing and intermediate care facilities. HEW has also assisted States in developing Hedicaid Management Information Systems (MYIS) which can perform many of the edits for, and provide the data necessary for3 coya- ducting a uti ‘Pimation control program for noninstitutional services (1 However, HEN has done Ilittle else in the area of noninstitutional utilization contro'8 m Utilization control programs for noninstitutional services been have requr'red since April 1 II 1968, when section 237 of the Social Security Amend- ments of 1967 (B.L. 90-248) became effective. Section 237 added section 3902 (aj(30) to the Social Security Act which requires State Medicaid plans to: "provide such methods and procedures relating to the util$- mation of, and the payment for, care and services available under the plan ***as may be necessary to safeguard against unnecessary utilization of stich care and services and to asswe that payments ***are not -in excess of reasonable charges conststent with efficiency, economy, and quality of care.'* Because payments for noninstitutional services represent about 40 percent lsf- Medicaid expenditures 9 utilization control over these services is important to the containment of overall Medicaid costs. Also, it is rmeported that nonlnstltwtional services are those where %P-aud and abuse $s most prevalent and utilization control programs can help detect and prevent fraud and abuse. Because little data was available about State utilization control practices within the Department of Health, Education, and WelfarrEc (HEW], we sent a questionnaire IX the 53 States and jurisdictions ws'th Medicaid programs. This report is based on the response to that questionnaire. THE QUESTIQNNAEWE On July 1'8, 1975, we sent a questionnaire 0~1 utilization control practices to 49 States (Arizona did not have a Mefficaid program), the District of Columbia, Guam2 Puerto Rico, and the Virgin Islands. Betweeul July and Ncvember 1975, we received responses from all of these jur-isdic- t-i ens ew?pt CSuam. 813 responding jurisdictions w-i 111be refer~~ed to as States iua thz’s report. -2- Because some of the questiorinaires were incomplete and fiecause some lef the responses were nat clear or conflicted GJGh others* we contacted virtually all the States to help insure we had an accurateS nation-wide picture of the Yec%icaid utilization control program for noninstitutional services 0 RESULTS~OF THE QUESTION!4AIRE The responses to the questicnnaire showed that, 012 the whole, the utilization contu~ol program for 3edicaa'd noninstitutional services was spotty. Idhile a Few States responded that they &id perform all or most of the edits and checks and pro613ce the data necessary for monitoring program utilization, most States --d perfort it relatively few of the edits and checks and only produced some of the neded data. The States that reported the more extensive utilization control programs were generally the States that said their claims processing c;erts met all syWc 0-F the MMIS requirements ar that their systems were awaitin 5 certification as approved MMISSI Because we bell'eve that the results of- the questionnaire could provide a valuable source of base line data OIZ State programs, a compilation of all of the responses to the questicsnaire is presented as Appendix I. Examples of some of the results follows Status of Implementation 0-F YNS Since the responses to th,a questionnaire ivldicate that States with PIMISs have better utilization control systems3 it appears that efforts toward developiq aflc$ operatin "WS are very -s"mportant to an effective utilization control system. At the time of our questionnaire, root much progress toward MMIS had been clsde as illustrated by the followi~'q two 'tables, Changes Needed for Seateas Claims Processing System to Ike% KMIS Requiremen% Change Needed Numbehnof S%a%es Claims processing system weds c~ivirig responses to be au%omated 13 Prowidea~ fi 4e needs to be automated Reference file needs to be automated Recjpient eligibili%y file needs %o be automated System needs improvement of infor- ma'cioua retrieval subsystem for managemen% repolrts 26 System needs improvement of infor- matiova retriewa‘% subsystem for uti 1izaGi0r-l upepor%s 27 Sys%em needs %CIbe modified so as to produce explanation of bwxfi%s 8 No changes needed 9 Other 17 Total ‘837 21 Note a: Total adds %o more than 52 because 28 S%a%es gave multiple responases. Since %he time of our questionnaire, the status of MMIS dmplementa- tion by the S%a%es &as improved. As of Sep%embc;r 19, 1976, 111 Sta%e clar"ms process-irrg systems had been certified as meet-img all PhiIS requiremen%s, 4 Sta%es were awaiting certificatfon, 18 states were in various stages 0-F developing an IWIIS, and 18 S%atrs were mznking prepatwtion~s to -initiate development of an !WHS, Oa?%y7 StaQes were %akfng no actiorf to ilrastall an PIMIS, The 3 %erarli%OrieS dQ riot par%icipa%e in the MPm y-%grm. Most S%a%es did nclt performs a%1 of %he edits and checks we iuaqwired abeu% m For example, oe?ly 23 S%a%es compared, few all types of' servicer, the serwlce prowided with %ke diagnasis to ensure consistency, Nisle%een S%a%es did this edi% for some servjces and 9 S%ates newer per-fouv-iwl %kis edi%. Comparable numbws for en edi% to de%ermisne if the diagnosis was consistent with %he recipien%'s sex were 22, 118, and 18, respectively, Also, only 29 States checked to see if pe~owiders were prescribing an wces-- s-ive amoun% 0-f s-larco%ic or dangerous drugs and 32 S%a%es did not have checks or edits to identify excessive use of ambulances, For States that did perform the warious edits and checks 9 we noted that there was a large vari ante among the criteria used tcl identify proviiders and recipients who might be providing or us’r”ng excessive numbers o-f serv4ces. Far exampI e 9 38 States said they checked to determine if a recipient was making an excessa"ve number of visits to the same provider, but the criteria used to tde~ltify such individuals varied flrom a ha”@ of not questioning clajms uwtill a recipient had seen the same provider more than 18 times im one month to a 101~of more than I vtsi t ip’t a month. An0ther example reel ates to a recipient receiving an excessive number of prescriptions whwe the 'criteria ranged from a high of 19 prescriptions in a month to a low of 3 prescriptions in a month. We also observed that many States that reported they performed a particular check or edit also said that the edit or check was performed mantdal‘By, Hn Our opiniorp $ many of the checks and edits wolal d be very di fficul ‘0: to effectively p~erform manually; for example9 checking If a service is consistent with the diagnosis where !wndreds of dfagnoses and thousands 0.0" services were involved. ‘This wodd be especially true if nonprofessional perssvlnel were doing tha's edit. Quality lof Care Reviews A number of States did nat have proglmams ts assess the qua”%$t.y of can92 pravided under 14edicaid. Twel ve States did not review the qua1 iity of care provided by physicians, 13 States did not revjew care prsvl"ded by dentists, 15 S-tatesl did not reviews care prow-i ded by optometrists (3 States did not provide the service)g and 13 States did not review services prwided by podiatrists and chiropractors (podiatrist services were not covered by 12 States, and chiropractic services were not covered by 22 States). The States reported widely varying numbers of personPae1 engaged %"ga uti"Sizatl"on contlrsl and qua‘liity of cane activities, We computed the ratio 0-f rewiewers to lrecipients of r3eda”cal services based on the average monthly number of recipienls.during fiscal year 1975. We could not ma&e the COW= puta-tions for I state. These cocputati oras showed: II 3urrber of States in Ratio Range Rbnorral Claims Qua1 ity of Care Ratio of Reviewers Professional Clerical Professional Clerical to Reci pi ents Revi cwers Reviewers Total Reviewers aevi ewe?rs Total Data not available ; 67 ii ii 1: 9 cl 2 4 2 1 3 1:2,501 ts I : 10,000 ii !i 1: 5 4 9 1:25,001 1:10,001 to %:50,000 1:25,OOO 5 5 6 7 46 .: 1:5O,QO1 to I :1OO,OQO 7 ii f : z 1 1:100,007 to 11200,000 3 over 1:200,000 3 3 2 ii I i Ten States reported that they could not separate their personnel between the two types of reviews, These States had ratios of personnel to recipi- ents ranging from I.913 to 3:253,836 for professional reviewersg from 1:7CN to 1:147,307 for clerical YTViEriSrS, and From '1:560 to 7~28,204 for total rwi ewerd a While MMIS does provide much of the data necessary for utilization controls it does not tell the State how to use the data desired. CQNCLUS IQl~lS At the time of our queslionnaire, there was wide variation in tl~e extent to which States had implerxnted a noninstitutional utilization control program. Many States were performing Lhis function manmally which is very difficult to do for many types of checks and edits. There was wide variation among the States in the criteria used to identify abnormal clajms and in dhe number of personnel used to review abnormal claims 1'01 relation to the number of recipients. Reviews to determine the qualjty of care pr~svided were nonexistent irt a number of States and only covered some types of services in most other StaLLes. Because of the time that has passed since the iss~1arw2 of our quest%cnnaire and because oU-ter ongoing reviews cover these areas, we are noit tz%ing recommendations relating 4x1 these concl us! ons 1 States were not able to px2ride us with data on the resul*ts of their noninstitutional utilizaLi0t-t re\~ie~4 3rogramsS even those States which ind-i- caLed .E;hat their claims processing systems met all the requirements for PIMHS. Eile believe that information on the resu'lts of the various State programs could provide SRS mana gerent and the States with helpful data to measure and compare the impact of such programs, We recommend that SRS ensure that the P;"uv13%Ss a"n use and being developed by the States have dhe capabiBi4z-j to accumulate ai-ld reporlz on the results of utilization c~Mro1 programs and that arrangement be made for lz.he reporting and dissemination es-f s~lch information, S-i merely yours ) lllllllll JL - - What is the Present Status of Your Medicaid Claims Processing and Information Retrieval System in Qual7tylng as an Automated System Under Section 235 of Public Law 924032 Number of States 6 23 QUESTI0N 5 Listed 0~1. the foIllowing pages are a number of nonlnstitutiortal services which may be provided under a State's Wedicafd plan. For each of these S@KViCQS) tRe foL?..~owfng infomation is summarized: --the number of States pnovidfng the service; --the number of States requiring prior authorization to receive the sewice; --the number of States Rating a quantity oae cost %itit estab%fshed for the servics; r. . .. 18 ghysician visits per year $500 ire private psychiatric care per year .100 hospita% inpatient visits per year 10 physician. ioffice visits per mmth I physlc%aw visit per msnth except 2\ visits apex mmeh are alBowed for a new acute condft%on Examples of prior authorization requ9rements * qUES?IOIi 5 (continued) Qutpaiient Hospital S@KVi@@S ?;?nker S&tes providing 0 :: this service to a11 Kedicaid eligibles o1 a a 52 Rmtbsr of States providing this service to sme Hedicaid eligibles o D o 10 Total nuder of States providing this service o D e Q a a D m D o e _ m 52 Examples of prior authdrization requirements a Laboratsry Services Scn't;er of States providing this serv-.-'-e to ~11 Medicaid eligibles o L e 52 ~umbzr of States providing this service to sox Medicaid eligibles OI O 0 Tlotaf number of States providir?.g this service O e D r) o ., ID ID D Q = _ O 52- ExamDles of cost cx quantity Pimit3 . . imo per year $200 per year of laboratory and x-ray combined .$50 per year of laboratory and x-ray combined FQP services rehted to lsosmetiic surgery For services ecpstbg over $25 ‘r-..-I- _‘I--.L ^..- -- of Si2teS providing this service to all Kedicaid ePigibles D a m y Vy7Cz'~ 2r of States prpviding this service to soze Medicaid eIL-EgibEes w O a Total ncz'oer of Steess providing this service mme e me mO mm _- _ m D . ._ ToPcal number of States pr&siding 52 Clinic sesTYvices Presckibed mugs . -- QUESTION 5 (continued) Prosthetic Devices Slizker of States providing this service to all Medicaid eligibles D e m 4Q Nwher of States providing Chis service to sane Medicaid eliglbPes _ ma 1 Total number of States providing this service O Q D I O -- * O a o 9 I I) 43, - Examles of cosEr 43'1:quantity Eimits . . $30 p Es device 'Examples of prim- authorization requirements Pm smg-iical%y 2mpSanted devices Pox- devfces over $25 For devices ovelr $50 and for au scentals of devices .. - .. QUESTTOY 5 (continued) Podiatrist Services Xmb2r of States providing this service to 22.1 I-Xicaid eli.gibles O _ m 410 ?$umb2r of States providing tRis service "co :XZ lIedicald eliigibles I m - CD Total number of States providing this service e a - n D O - m q o - - O 40- Exaoles of cost or quantity limits . . \300 per month flop outpatient ExampSes of prior authorization requirements lllll Illllll . QVES?SOS 5 (con!ku~ed) Examples of prior authorization requbrememts Q%h@kTransportatfon -- . Does Your Stateus Processing System Contafn Any Claim Review Mechanism Eefore the Claim is Entered Hnto the Automated System? 813 the following pages is a list of edits or checks that may be performed by a Statevs claims processing system. Ulndear each type sf edit we have s~rmmarized the number of States which: --perform the edit; --perform the edit manually; --perform the edit autzomatically; --pfzcf0m.l the edit on a19 c%aims; and --pex3orm the edit on a sample of claims. the State repolrted that its respePnse to tkis question would have ts valry frsm 0n.e cmmty ts mother. Theuefore, this State's aata is not i.ncltaaed in the snmmaq of responses fopr this questfon. . QJESTIQN 8 (continued'I Pledical Service Consistent With Diagnosis XSumber of States This edit is performed manually for all types of services . c QUESTION 8 (continued) Nedical Service Consistent With RecipientPs Age 1\Tlimber of States 22 8 Illllll 8 Illllll 7 Illllllll This ~edit is pea-formed on a sample 0% claims for types 0% servLce.8 provided; manually for some types9 automatically for others..,. 0 F QUESTIOrW6 (continued) Medical Service Consistent With Recfpient9s Sex. Medical Service Consistent With Recipient's Sew c XuzlSer of States . t$UESTIOW 8 (continued) ITlImber of States 26 provides; on all claims for some types, on a sample 0% claims for others “~~“~~~“a~~~~~D~~O~~~~~~~~~~~~~~~~~~~~~~~~~~~ This edit is perforized aueomaticaPly for all types of services prcvided; on all claims for some types, on a sample of claims for others *~I~~~r~~001~~~"~"~~~~~~~~~~~~~~~~~~~~~~~~~~~ This edit is performed for all types of services provided; manually for SOT;12types, automaticaEly for orhers; on a91 claims for somi? types, on a sample of claims for others....... This edit is performed manually for some types of services provided; on all claims for some types, on a sampke of claims for others ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ This edit is perforned automatically for some types of services provided; on all. claims for some types, on a sample of claims for others ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ This @air. is performed for some types of services provided; nanually for some types3 automatically for others; on aPI claims for some types, on a sample of cl.aims for othekO....., I _I QUESTION 8 (continued) lll .Dfagnosis Consistent With Rec&p$&rit?s ABe . Number of States This edit is performed manually for all types of services provided; on all claims for some types9 on a sample of claims for others D~~~~~~~~~~~~~~0~0~~~~~~~~~~~~~~~~~~~~~~~~~~~ 2 This ddit is performed automatically for all types of services . provided; on all claims for some types, on a sample of claims for OthePS ~O~~~ODO~O~~~~OD~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 0 This edit is performed fole alI. types of services provided; manually for some types, automatically for others; on aPS. claims for some types9 on a sample of claims for others....,., 0 This edit is performed manually for some types of services provided; on alP cEaims for some types, on a sample of claims fom: others ~~~~D~~~0~~D00~~0000~~~~~~~~~~~~~~~~~~~~~~~~~ 0 This edit is performed automatically for some types of services provided; on aLP cPaims for some types, on a sample of ckb31s for sthers 00~~00~00*~~~~0~0~0m~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ . 0 This e&it is performed for some types of services provided; manuaily for some types, automatically for othbx; 8x2 afl claims for some types, on a sample of claims for ~thers..,~.,, %p c . k3' a llllllllllllllllllllllllllllllllllllllllll -&WlYION 8 (continued) Dfagg-iosis Consistent With Recipient 's Sex This edit is performed on a sample of claims for types of services provided; manualfy for some types, automatical9y fsr others,,,, 0 Diagnosis Consistent Wth Recipient's Sex Sumbev of States This edit is performed manually for all types of services 2 . Listed on the foPPoting pages are types of information which may --o7hether the information is produced manually or aueomaticafly. Total Utilization by Type of SeErp;iice Kw3ber of States p'~~oduiL.ng Infomation produced every X'umber bpf States prochxfng . QUESTION 9 (contiouedj Total Tkilfzatiore by Type of Service and Cash Assistance Category of Recipient B B 22 23 44 2 2 c QCFSTION 9 (continued) 'fat&l. U~iPization by Type of Service and Age Group of Recipient . QUESTION 9 (continued) Total ~eilizat~on by Type of,Service -and Sex of Recipient Number of States producing this information every 6 x~onths..~~-. 8 Iafomatfon produced each year - Tna~ually,............m-.......D - automaeicaEly,.~O.~...m...D.-.o Number of States producing this information. each year.........o. Utilization ProfiPe for Specific Recipient Kumber of States producing Information produce6 every Number- of States producing Wumber of States producing this information on special request.. a QUESTION 9 (continued) Services Provided by Specific Provider_ Kmber of States producing this infon.ation each ~-eek.....~..... . _ . I Listed on the %ollowing pages are a number 0% edits IThich a State may/ . 'perform in its claims mocessim svstem. Fan: each 0% these edits we ~smmarized the nmbem: of States which: --routine2y identifies the particular edit %or review; --identifies the edit be%ore payment 0nPy; --identifies the edit after payment only; --identifies the edit both before and after payment; --require prior authorization; --do not require prior authorization; --review claims with the aid 0% a specific norm or exception criteria; and --review claim without the afd 0% a speci%ic norm or exception criteria. Examples of norms and exception criteria is also included for each of the edits listed, 3kEber of states before payment X.rher of States after peyzent Xmber of States Excessive Visitis to the Same Provider by the Same Recipient 38 0 0 14 52 11 20 7 38 1 5 2 8 Excessive lhrnl~er of Prescriptiors Krirten by Practitioner where this is identified for review - 35 - n CD $6 52 a 23 5 35 % 8 2 %si -.---- Qiz>,l~Xi IO (continued) Excessive Use of Ambulance Services Nuzber‘of States where this is identified for review before payment Kumber of States 2.f t2r payzent Ember of Stares where this is identified for review both before azd after payment a 0 D o e a a e a e a e - e I- L1 - o G m ib Total. number of States identifying this for review 0 D 0 O.. e o - o1 ,I8 kmber of States where a sample of claims are ramaLLy reviewedwithout the aid of specific nOT;I?, Or exception criteria ~ D q mD D o o s a e I p e D o - m a m oI 0 Xcr3be; of States where claims are reviewed manually without the aid of specific norm or exception criteria o - o 0 - 0 0 8 Ember of States which said this was identified for review but codd not provide sgecjific norm or kception criteria - 0 - 0 - - 2 Total. number of States where claims are reviewed without the aid of specific norm or exception criteria 0 0 mm+ m-(. 10 Examples of noPrZaor exception crPteria: More thala 1 tlrip per person or family per day More than 4 trips per person per moglth More than the mean pPus 2 standard deviations Ex.cessive MedicaP Visits Per Family Suder of States where this is identifierI for review - e : mo I - p - Rzber of States where this type of service is not proa-idec? D I) ~ Ku%ber of States Xuxber*of States where this is identified for review befare paperet OO~O..~~.O.O.DO.OD~~~~~~* D0 Edber of States where this is identified for review af",er papzent RTuzber of st2tes both before and af'ter payment w D LL m m D D e LL O m LI - Q .D m m - - m Total nuzlber of States identifying this for review q ., o -.O o - - - D . - .- Ember of States b7here a sample of claims are ranuelly reviewed vithout the aid of specific : mrz or exceiptim crite15a o o ~ o o I) e I) q e m m II l a - o I - = - ?k&er of SeL2tes 57here claims are reviewed manua%%y .- wit'fio=t th2 aid of specffic nom or exception criteria 0 * - 0 Q- - Giber of State6 Ic:hich said this was fdentffiecl fpr z&~iew but could 120%:provide specific norm or exception criteria - m- Q - - Total number of States where claims are reviewed without . _ the aid of specific norm or exception cxiteria m m m m m m o pl o D (I II . Excessive Pbdiatry Services - Kumber of States where before payment ~ ; Xud3er of Stares Cl-k&e Excessive Physician Visits to Patients in Medical Institutions xmiber OE states Siiber of SZates provided ~ ~ a K.miber of Stzttes Nwztber of States I Yhsufficienr: Physican Visits to Patients in Medical. Institutions -. -.- 33--j, - of States where this is identified for review M-~-527 - of- States where this type of service is not provided D o ~ ~ o a D m ; o o II a o a m o q a *. m kzber of St.ztes where this is not identified fsr re-.-is but where a11 services of this type require prior authorization ma e a + V D OD Oo g e e - Eh'uAer of States where this is not identified for review 2nd does; not require prior authorization ~ Total. number of States aresponding to questionnaire o Nmbe~ of States where before payment m q Kucber of States Ghere after: payr,ent s 0 0 * 0 D D * 0 0 I) * 0 0 e II m 00 Wm3er of States where this is identified for review both before and after payment V a m m a O D O a m o Total number of States identifying this for review . o - .. Kumber of Srates where a sampk of claims are sanaally reviewed without the aid of specific nori or exception criteria ~ D o mo e e I I * D m kkzber of Stgtes where c3iaims are reviewed nanual%y without the aid of specific norm cpr exception criteria - mn 0 0 - - 4 Wuxber of States which said this was identified for ~evie.w but could no%: provide specific norm or exception criteria - - - Q- 0 Total neznnlillerof States where cla%ms are reviewed without Zhe aid -of specific mm or exception criteria + m m o o o o a i o -* m 5 Numberof States before paymen$: Number of States aft2r papent Rmber of States Number Of States where a sample of claizs are manually reviewed without the aid of specific non3 QK esception criteria o ~ * r) 0 * e 0 a a * D * - (0 - 6. - * * - &B ITumber of States where claims are reviewed namallly without the aid of specific lclorm or excegtioa criteria 0 - 0 m* m05 Nlmber sf Seates JW?.liCh said this’was identifiei for review but cou%d not provide specific nom or except%or? criteria - 0 a 0 0 * 2 TcPtall mmber of States where claims are reviewed without _ Excessive Nunber 0% Emergency Visits to a Dentfst- Rz&er-of States before payment n'u32ber of Stares aft2:r pa>ment $kc1:3er of States Physicians Performing Many Surgerfes Number of States where this is identified before payment Number of States where a szxnple of cEa%m are maraually reviewed without the aid of specific norm or exception criterfa ~ ~ ~ o o o e D a m D L) a I D D o - a ID o Kumber of States where claims are revissed ~lazzd.ly without the aid of specific mom or exegtiom criteria e - - * - 0 - 10 Rumber of Slrates which said this was iZentiSfed for review but could not provide specific norm of except503 criteria - 0 - - * * 3 Total number of States where claims are reviewed without the aid of specific nom or exception criteria. D 0 a D 0 m e (I e m D .I4 Examples of norm or exception criteria: lkwe than 2 SL%Kgeries I&n a day More than 40 surgeries per year for geme~al practitfom~rs i%re than IL per persom per year More tha Z per penzoa per 3 momths More tham I per person per momth More tham the mean plus 2 standascd deviations Excessi7je Number of Institutional Admittances by a Practitioner Wu&er of States where this is identified for review I - i - - e ,+ e -2~) Kclber of States where this type of service is not provided ~ ~ o D ~ ~ e 0 ; ; 0 0 - 0 o 0 o mm- - m- v p _ m : -.a 0 Kumber of States where this is not identified for reri2Tn; but ihe?Te d.1 services of this type require prior authorization OOe OO+ a e a O- - a n q e Q+ (1 a. e e e W 8 Nudl 21 of States where this is not identified for review and does not require prior authorization o m* : q D D - o -28 Total. number of States responding to questionnaire (D - e - p a m .--a .52 Sthmber 0% Stetes vihere a sample of claims are _ -EanuaELy reviewed without the aid of specific non 03t exc&tim criteria (I ~ (1 a e e o (1 a m a m LI l a D D D Q m m 0 K&her of States where claims are reviewed manutally witSout t'he aid of specific norm or exception criteria 0 0 - Q - 0 m8 kmber of States which said this was identified for rewie%7 but could noi: provide specific norm or exception criteria * - 0 m* 0I Total number of States Where claims are revfewed wfthout - - the akl of specific norm or exception criteria, (I O D D O O O*~ D o- o .9 Examples of norm or exception ckiteria: More than 25 perccent of patjiewts Moue t&m % per penion per year More than the meaw. plus 1 standard deviat:Ion Mme than the mean plus 2 standamtd deviatims More than 7 admittances pea: 100 patients m Exampfes of norm or exception criteria: Excessive Referrals to Other Practitfoners bath before arid after payment ~ D o I) o Prequerit Replacement of Eyeglasses Frequent RepPacement of Dentures Ember of Stetes where this is identified for review I - i q e L - D - 20 Number of States where this-type of service is not pKovided ~ ~ 0 =.~~.*.~OD*~" f""""""""""'" * -0 . Kuiher of Stat2s where this is not identified for Examples of nom or 2xceptiow criteria: Maare than 1 set iof dentures per year More tha.n E set of d27dx1res per 2 years More tha13 1 set of dentures per 5 years Nxe than 1 set of d2ntures per 10 years Mcwe thaa 1 relfne of dentures pea” 2 years Mcme than the aem plus 2 standard deviations Fscequent Rep,lacement of Hearing Aids where this is identified for r2view llllnmnnlllllllllll IIllllllllllllllllllllllllllllllllllll Prescribing 0% Narcotic or Dangerous Drugs More thaua. 10 per gatfent per month More than 4 neuroldgicals per patient per month More tlaan 3 per pati2nt per mcmtb More tha~a the MWM plus 2 staad~rd devfatiows ExcessivQ Nuber of sma1a Quantity Prescripeions Excessive Rmber of X-rays for a lRecipient Wudber of States where this is identified for review l;uder of St2tes wS2re this type of- service is nor p33viaea o ~ ~ ~ * * rn @ 0 ; n 0 * 0 r) Q s a a * 0 kmber of States where this fs not identified for r2%-iev jut :Z~~re 211 services of this type require prior 2uthorizatioa q f e D m D D o q o m o - o .- Xur232r of States xhere this is not identified for review 2nd does not require prior authorization ~ Total mmber af States ~espondiotg to questionmire o without the aid of specific norm QK exception criterJa - 0 0 = * Q Ether of Stetes wlrich said itSis was identified for &iew but could not provide specific nom OK exception criteria - _ - 0 - - 4 TlotaP nmiber of States where cEaims are reviewed without- . the aid of specific nom cx errception cpi~elia.,....,..,,......',..,.. 14 5 x-rays per month I. X-ray pe9 2 visits 4 x-r.ays per 6 visits $50 im x-rays in a m0rd.l $SQO in x-rays in a year tAe mean plus 2 stanclard - . Excessive A'mber of X-rays by a Practitioner Excessive Number lof Laboratory Tests for a Recipient . 3 i rW?tS pQK tiait 10 tests per month 5 testa per msnth 52 tests per year 4 per 2 visits $50 of tests in a noont% $100 of tests in a gear the mean plus 2 standard devfations - . Excessive Kutber of Laboratory Tests by a Practitioner $iGmber of S-reeeswhere a sample of clai3 are manually revieweci wifhoue the aid of specific nom or exception criteria ~ I mD e Qmo o I e - - Q- m- - - * 01 Ntzmber of States where claims are revieh;ed nailuaE3.y wiehorrt the aid of specific norm or exception criteria - 0 - 0 0 0 42 Kumber of Szafies ~Aich said this was identiffed for revie-J but could not provide specific ROT"- or exception criteria - 0 - * - *f TWal number of States where claims are reviewed witheut . - Examples of norm or exception criterPa: 4 tests per ptient per 2 visits of tests to patients is greater than 60 percent the .mean plus 1 standard deviation Receiving Narcotics or Dangerous Drugs * QUESTIOM 11 Who' Reviews C1al"m.s That Exceed the Norm Or Exception CritePnia? Number of states How &my Personnel (on a full-tir,e eq,uivalent basis) Are Assigned to Review Claims Which Exceed the Sorm or Exception Criteria? How Nany Personnel Are Assign& to Conduct Quality of Care Reviews7 Employees Reviewing Claims Kkkh Exceeded Worm Or Exception Criteria The total nuder 0% professiozzl and clerical staff assigned this function ranged from 0 in 4 States to as many as I.44 in one State. One quarter 0% one professional staff member's time was devoted to this function in one State corpared to 53 professional staff assigned full-time to this krtction in another State. Seven States had no clerical personnel assigned to this functfon whereas one State had 91 clerical workers performing these reviews on a full-time basis. Employees Performing Quality of Care Reviews The total number ofprofessiozzl and clerica%, staff who conduct qualitj~' of care reviews ranged fro= 0 in 9 States to 580 in one State, One quarter of one professional stzaff member's time was spent conducting quality of care reviews in eze State compared to 370 professional staff assigned full-time tc i-his function in another State. Thirteen States had no clerical staff involved ln conducting qua%ity of care reviews whileone Stare had 400 clerical staff performing quality of care reviews. Employees Reviewing Claims Khfch Exceed Norm 01 Exception Criteria and Also Perform Quality of Cqrk-Reviews The total number of pro%essior?zl. and/rjr clerical staff performIng both of these utilization review 5knctions ranged from one quarter 0% one staff member's time ilo one State to 494 full-time staff in another Stx?L@ce. Same Employees Performing Reviewing CPaims Perfoting Quality Both Reviews (State Coufd Exceeding Norm of Care Revjews Not Separate Time Spent on Each Review) No. of No. 0% so, 0% employees States States 0 3 0,25-5 17 5 * 25-10 5 10.25-20 6 20.25-50 3 51-100 a more thaa 100 1 varies 1 N/A Number 0% States 25 2 -1 28 30 --for someservices 3 =--depends on county li 34 Ptpofi les for a sample of 12 7 of such provfders: Profiles for all recs”pients and providers always available for al1 services from the computer D m m O O O I t I m m mVm None of these: One type of prof-p”lPeI isted above is produced folr r*evfew m m D 8 Two types of profiles I isted above an3 produced for review o m 31 Three types of proffles ‘B$sted above are produced for review D 1 Four types of profiles listed above are produced for revfew m O4 HOW Frequently are quality of Care Reviews Conducted for the Following ProvidersP Physicians Nuder of States --Continuous (ongoing) --Weekly --Monthly --Quarterly --Annually --By special request --Not at all c --Continuous (ongoing) --Weekly --Monthly -- Quarterly --Annually ---By special request --Not at all. Optometrists --continuous (ongoing) --WC3Zklp --Nonthly --Quarterly --Annually --By specfal request --Not at au -- --setiice dot provj.ded QUESTXQN 15 Ccondinued) Nmber of States Podiatrists --Continuous (ongoing) 16 --Weekly P --PJl0ntKi.y 2 --Quarterly 1 --Annually 0 --By special request 7 --Not at all 13 --Service not provided 12 52 = --Continuous (ongoing) 8 --Weekly 0 --l%mrh%y 1 --Quarterly 2 --AnnuaPly 1 --By special request 5 --Not at all 13 --Sewice not provided 22 52 = --Continuous (ongoing] 12 --Weekly 0 --NonthEy 0 --Quarterly 0 --Annuafly 0 --By special request 2 --Not at all 5 --No response 33 3=T G . QUESTIOM 16 Who Conducts Quality of Care Reviews? Ntmtber of states QUESTION 18 On What Basis /Are Quality of Care Reviews Conducted?' Number of States From provider claims identified as exceeding norm or exception criter'8"a a s O D o (I m m m o a O O D D e m m 34 From provider profiles idenlifed as exceeding norm or except-t"on criteria O II II I O D O o1 O D o m m m D il O D 26 From recipient profiles identified as exceeding norm or exception criteria m m D a D O D o m O D D O o (I I m O 27 From a sample of provider cla!ms p D D o O I I D o I q' D D o m D 20 From a sample of provider proffles O D o I) D e O o II m m m m I m 98 From a sample of recipient profiles O OO a mOD D o Oo D D m Qither. * 0 0 I m I) a 0 P a 0 0 0 a 0 0 m a I II II 0 @ IO m m m z States using one of the methods llsted above I p o p a g p ( O I 5 States using two of the listed methods above D O s m m I I m O 8 States using three of the methods l!sted above m m m D I) I) O e 17 States using four of the methods listed above e II m m m m o m m 7 States using five of the met&lods listed above m m D m D m O D o, 0 States usl'ng six of the methods Ifsted above O O m O I O D p m m 3 States using seven of the methods listed above o m m p m O m D p 3 No quality of care reviews performed D O I) I) ( m D O p D O D o, O 9 g -
Survey of Practices To Control the Use of Noninstitutional Services Under Medicaid
Published by the Government Accountability Office on 1977-03-16.
Below is a raw (and likely hideous) rendition of the original report. (PDF)