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¨      Capitation Toolbox – Introduction; Behavioral Health Services; Capitation fundamentals; Direct access to specialty care (self-referral); Capitation Pros and Cons; Medical Loss Ratios; DRG payment systems; HMO Pools; Readiness Audit List; Levels of risk in capitation; Adverse selection; Medical group/IPA responsibility; Sponsor Discounts; Contracting Issues; The capitation contract; Physician and other ambulatory visits per year (average); Hospital Admission Rates and LOS – All Payer; Capitated HMO contract, Representative major financial pools; 

Capitation expense allocations; Risk sharing arrangements (table); Flow of funds, algorithm – representational example; Capitation payment date issue in relation member enrollment; Hospital per diem rates/discharge timing considerations; Physician Encounter benchmarks; Critical success factors for managed care organizations, checklist; Capitation rate example; Health Plan Operational Metrics; Physician Encounter benchmarks; Specialty Physician Payment Systems; ‘Per Case’ or global package pricing strategies; Contact capitation; Specialist capitation; example strategy/plan; Pay for Performance (P4P) programs; Ancillary provider contracts; Medicare ‘Fraud and Abuse’ /Health care compliance; Medicare is targeting costly physicians

¨      Utilization/Resource Management Toolbox – Introduction to Utilization Management; Guidelines; Effect of guidelines on care; Medical necessity – What is it?; Case Law Citations – related to medical necessity; Length of Stay Guidelines/DNR orders; Unplanned readmissions w/audit form; Tracking new federal regulations;

¨      Utilization/Resource Management Program; Program elements; Referrals within the medical group; Medical necessity; Outreach; Communication concerning UM policies to patients and the public – example; Program elements; Report requirements; Pharmacy Management; Documentation requirements; Utilization Resource Management Department; Discharge delays; 

Basic elements of an UM plan (refer to UM Plan model in addendum); Consultations vs. referrals; UM Department staff and staffing; UM Committee;  UM Policy and Procedures – example for medical group/IPA/MSO; The Review Process; Assignment of Case Numbers P&P; 

¨      Benefit and eligibility determinations – Identification card; Financial Responsibility Guarantee Form; Eligibility and Benefits Verification – P & P; Precertification/Certification Worksheet; Eligibility FAQs;  

¨      Case or Care Management (CM) - Introduction; CM program savings; Hospital UR/Case Management – functions; CM roles and responsibilities; Primary Case Manager – Role/Responsibilities; Hospital Case Manager – Role/Responsibilities; Specialty Case Manager – Role/Responsibilities; Specialty Case Management; P & P;  Specific disease examples for case management services; Criteria for Social Service/Counseling Management; SCM case closing; P & P; SCM discharge form example; Hospital Case Manager UM Variance Reports, example list; Preadmission Review/Precertification or ‘Precerts’; Hospital charges for non-covered services; Preadmission case management screening tool; 

Procedure for prospective review; Prior authorization check list form; Diagnostic referrals; Diagnostic radiology referral form; Procedures for ‘Patient Care Plan’ form completion prior to review; Authorization Request Form; Request for Authorization - additional mental health services; form; Request for Authorization to provide additional services; form; Physical Therapy note; Request for continuation of services; form; Referral Authorization form; Review Worksheet form; Reviewer Communication Form to Requesting Provider;  

¨     Observation status for acute care - P & P; 

¨      Review Process – Role of the physician advisor, Concurrent and Retrospective; Concurrent review; policy & procedure; Concurrent review, work sheet form; Concurrent review check list form; Authorization review work sheet form; Length of Stay and next review date assignment;  ‘stickey’ example; Specialty pre-admission authorization; Blended Specialist-Primary Care Physician for a Qualifying Patient; Primary physician notification; P&P with form; 

Retrospective review, policy; Inappropriate admission - change in status;  Discharge planning; policy and procedure; Authorization of special services; Periodic review of pre-authorization policies – example; Specialty pre-admission authorization; Primary physician notification; P & P with form; Authorization approval notification form; Authorization denial notification form; Outpatient surgical authorizations; procedure; Complications following non-covered services, policy; Custodial care, definition; Audit for Access Time to Specialty Care Following Primary Care Referral.

¨      Ambulatory Services Management - The Minnesota Medical Practice Model; Out-of-Pocket (OP) Patient Expenses; Outpatient surgical authorizations, procedure; Podiatry Services;

¨      Referral Authorization Strategies – ‘Passthroughs’ or ‘Automatic’ Approval or ‘Direct Access’ – example list; Streamline referral process; ‘Open Access’ + example P & P for Chemical Dependency; Delegation of UR function to selected physicians; Specialty physician delegated procedure list, by specialty; Urology referral check list; Orthopedic referral checklist;

¨      Emergency Services; P & P; Alternative care or redirection of care; References and resources related to ER services; ‘Out of Area’ Care; P & P; Procedure for ‘out of Network’ Arrangements for care; Letter/Contract to ‘Out of Network’ provider; Payments for Emergency Services to Non-contracted Providers – California Law

¨      Home Health Care; Home Health/Hospice Case Management, Policies/procedures; JCAHO Emergency Preparedness for Home Care; Home Health/Hospice - Case Management; Homebound criteria; Common reasons for failure/lack of use of home health services, Skilled Home Nursing Care; Home Nursing for Ventilator or C-PAP Patients; 

Physician directed homebound program, Home visits by physicians following hospital discharge; Care Plan Oversight; Home health care referrals, P & P, Termination of home health care services, Home Health Aides/Assistants; Caregivers; Home health infusion services, Oxygen coverage guidelines, Home Safety Visit Checklist, Hospice; Eligibility Requirements; Hospice benefits; Hospice care in a SNF;  Karnofaky Performance Scale; Home Health Care for Psychiatric Services;