oversight

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)

      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
                                                                         -