Medical Management

The Medical Management (MM) Program provides a framework for continuous assessment and improvement of health care delivery and service. It also provides for monitoring the use of services and evaluating the appropriateness of care.


Purpose of the Medical Management Program

The purpose of the Medical Management Program is to foster access to appropriate, quality and cost effective care for members, within the scope of covered benefits. Medical Management involves the assessment, evaluation, planning, and implementation of health care services. Medical Management is closely coordinated with case management and home health care programs, which promote quality of life and the utilization of additional, appropriate resources throughout the continuum of care.

Medical Management Program is designed to improve the quality of clinical care and services provided to Plan customers.

The goals of the Medical Management Program include, but are not limited to:

Enhance Effective Medical/Utilization Management:

  • Continue to align MM functions with risk and successful performance.
  • Continue to recommend and refine actions that support continuous improvement to structure, process and outcomes.
  • Continue compliance with all Federal and Local regulatory requirements.
  • Attain compliance with HIPAA and maintain compliance with ERISA requirements.


Align Medical Management to Deliver Quality Care & Services:

  • Manage cost of medical care through improved utilization of services, working closely with hospitalist to manage on-island hospital utilization.
  • Measure, trend and analyze MM activities against performance goals and/or recognized benchmarks.
  • Strengthen discharge planning activities and coordination of care with Case Management and Home Health Care programs.
  • Assess core competencies of Medical Management staff, provide continuing education & address opportunities for improvement.
  • Improve Member and Provider Satisfaction with Medical Management:
  • Establish stronger relationships with primary care physicians in order to improve communication lines, the referral process and member and provider satisfaction.
  • Continue to assist Contracting to develop improved out of area networks with competitive reimbursement.
  • Support efforts to improve access and availability of specialists.
  • Monitor timeliness & consistency of MM decision making.


Improve/Maintain Systems that Impact Delivery of Care:

  • Continue to support the core system & reporting capability to promote continuity and coordination of care by improving documentation and access to data.
  • Support and refine systems that identify at risk populations and coordinate with disease management and case management interventions.
  • Utilize pharmacy reporting to identify members at risk populations & provide feedback to practitioners.
  • Refine & enhance the case management program, educate practitioners on program utilization and provide feedback.

Monitoring and Evaluation:The MM Program’s scope includes, but is not limited to, monitoring and evaluation of the following:

  • Services provided in acute care and rehab hospitals, home care, skilled nursing facilities, subacute facilities and other treatment centers.
  • Appropriateness and medical necessity of pre-authorization decisions.
  • Timeliness of the referral and authorization process.
  • Completeness and communication of denial decisions.
  • Adequacy of member communications regarding denial decisions and members rights of appeal.
  • Use of objective measurable criteria for making utilization decisions that are based on reasonable medical evidence.
  • Consistency of utilization decisions by health care professionals involved with utilization review.
  • Appropriateness of discharge plan and follow-up services.
  • Identification of quality of care issues and concerns.
  • Member and provider satisfaction with utilization related processes.
  • Utilization trends including under and over utilization.
  • Appropriate and consistent administration of benefits.

Concurrent Review Process: Concurrent review is the assessment of medical necessity or appropriateness of services as they are being rendered. Concurrent review is conducted by a trained clinical staff via telephonic or on-site visits to monitor appropriateness of treatment or length of stay, as well as facilitate or coordinate discharge planning. Concurrent review of on- island cases is done through daily on-site visits to accredited hospitals. The hospitalist works collaboratively with the concurrent review coordinator to ensure that care provided is clinically appropriate and that length of stays (LOS) are within the recommended standard guidelines. This process is critical in maintaining effective resource utilization and cost containment.

Concurrent review is performed by trained clinical reviewers, in consultation with the physician, using as a basis, pre-approved medical necessity criteria. Reviews may be telephonic or on-site and may include but are not limited to:

  • Inpatient Length of Stay (LOS)
  • Severity of illness
  • Intensity of service
  • Under and over Utilization Management
  • Disease/Case Management
  • Discharge Planning
  • Identification of potential quality related occurrences

Criteria: Medical Management uses specific utilization criteria based on sound clinical evidence through the use of Milliman Guidelines as well as internally developed criteria.  Actively practicing practitioners from various specialty areas are involved in developing review criteria. 

Utilization review decisions are made in accordance with currently accepted medical or health care practices, taking into account the needs of individual patients and characteristics of the local delivery system.  Criteria are objective, clinically valid, compatible with established principles of health care and flexible enough to allow deviations from the norm when justified on a case-by-case basis. Criteria are used only to determine whether to approve the requested treatment.


Utilization Decisions: Medical Management policies outline that qualified health Professionals are utilized to conduct reviews and assess clinical information. In addition, appropriately licensed health professionals supervise all review decisions.

All utilization decisions (including prior authorization, concurrent review or retrospective review) are supported by relevant clinical information appropriate to each case (such as medical records, lab/x-ray results, ER treatment records, etc.) and consulting with the treating physician, as needed. Qualified practitioners and/or clinical peers from appropriate specialty areas are utilized to assist in making determinations of medical appropriateness as indicated.

Decisions are made in a timely manner to accommodate the clinical urgency of the situation. Medical Management policies outline specific timeliness requirements for prior authorization (pre-certification), concurrent review and retrospective review. Policies also outline the requirements for timeliness of decision notification to members and practitioners.