Benefits Monitoring Program (BMP)

1. Benefits Monitoring Program(BMP) Upper Peninsula Health Plan

2. What is the Benefits Monitoring Program? • The Benefits Monitoring Program (BMP) is a Michigan Department of Community Health Medicaid program that allows the health plan to monitor and assure the medical necessity of services for members who engage in misutilization of benefits.

3. Purpose of the Program • Modify the member’s improper utilization of Medicaid services through educational contacts and monitoring. • Prevent fragmentation of services and improve the continuity of care and coordination of services. • Assure that members are receiving health care services that are medically necessary and supported by evidenced-based practices, thereby curtailing unnecessary costs to the program. • Promote high-quality health care for Medicaid members. • Reduce overuse and/or misuse of Medicaid-funded services (including prescription medications). • Analyze members patterns of utilization of health services. • Prevent harmful practices such as: • Duplication of medical services • Drug interactions • Possible drug abuse

4. BMP Program Functions • Identification • Who is misusing or overutilizing services? • Evaluation • Are services utilized appropriate for members? • Education • Does a member understand appropriate benefit utilization? • Monitoring • Are interventions working?

5. Identification of Potential BMP Candidates • State Identification • PROM (PROgram Monitoring)system • UPHP Member Identification • Member comes on the plan already in the BMP program. • Identified by internal utilization review. • Possible fraud? • Overutilization of services or medications? • Provider Identification

6. BMP Enrollment Criteria • Criteria for beneficiaries to be placed in the program include: • Fraud • Inappropriate use of emergency department services • Inappropriate use of physician services • Inappropriate use of pharmacy services

7. Fraud • Selling or purchasing products or pharmaceuticals obtained through UPHP • Altering prescriptions to obtain medical services, products, or pharmaceuticals • Stealing prescriptions or pads; provider impersonation • Using another individual’s identity, or allowing another individual to use a member’s identity to obtain medical services, products, or pharmaceuticals

8. Misusing the Emergency Department • More than three emergency-department (ED) visits in one quarter • Repeated ED visits with no follow-up with a primary care provider or a specialist • More than one hospital ED facility used in one quarter • Repeated ED visits for non-emergent reasons

9. Misusing Pharmacy Services • Using more than three pharmacies in one quarter • Abnormal utilization patterns for: • drug categories listed over a one- year period or • More than five prescriptions for drug categories listed in one quarter • Drug Categories • Narcotic Analgesics • Barbiturates • Sedative-Hypnotics, Non-Barbiturate • Central Nervous System Stimulants/Anti-Narcoleptics • Anti-Anxieties • Amphetamines • Skeletal Muscle Relaxants

10. Misuse of Physician Services • Utilizing more than one physician or physician extender in different practices. • To obtain duplicate or similar services for the same or similar health services for the same or similar health condition. • To obtain prescriptions for the drug categories mentioned in the previous slide.

11. Member Enrollment Process • A member is identified as having abnormal utilization. • An identified member is referred to the UPHP Case Management (CM) program for review. • The CM staff verifies that the member meets the minimum BMP criteria. • Recommendation for BMP enrollment is sent to the UPHP Medical Director for final approval.

12. Member Notification and Enrollment • The member is sent a letter notifying him or her of their placement in the BMP program. The notification will include the following: • Information regarding the utilization patterns and concerns • The effective date of enrollment in the BMP. • Instructions on the selection of potential providers • ** Must be approved by UPHP. • Members are placed in the program for a minimum of two years (24 months)

13. Member Notification • The member has 10 calendar days to contact UPHP and discuss the findings prior to the enrollment effective date. • If the member is restricted to certain providers, a second letter is sent that lists their BMP assigned providers. • If UPHP has reason to suspect that a member-selected provider will not contribute to a reduction in utilization, the selection may be denied

14. Member- Appeal Rights • Members cannot appeal being placed into the BMP program; however, they can appeal restrictions that the health plan implements. • Members must ask for this hearing within 90 days of the date of the BMP notification letter. • A request form is enclosed with the BMP letter. • Members can also request a State Fair Hearing by calling UPHP at 1-800-835-2556.

15. Enrollment Changes • Changes in enrollment: • The member will remain in the BMP for the minimum time period of 24 months regardless of any change in enrollment status. • When a BMP member has a change in enrollment, responsibility for monitoring that beneficiary moves from UPHP to a different Medicaid health plan or to Fee-for-Service Medicaid, provided that member remains a Michigan resident.

16. BMP Control Mechanisms • Not allowed to fill or refill controlled substances until 95% of the medication has been consumed. • Restricting members to working with a: • Specific primary care provider • Specific pharmacy • Specific outpatient hospital • Specific specialists physicians • Specific group practice • UPHP may also choose to restrict members to specific prescribers for controlled substances.

17. Exempt Services • Services rendered at a local health department • Hearing services • Podiatry services • Chiropractic services • Services rendered by a non-prescribing mental health provider (e.g., MSW’s, P.h.D.s, professional counselors, etc.) • STI screening and treatment, family planning, and related services • The following services may be exempt from the BMP Control Mechanisms: • ED services • Dental services • Services rendered by a nursing-facility provider • Services rendered in an inpatient hospital • Hospice services • Vision services

18. Who will be the BMP Provider? • The BMP provider will be the member’s primary care provider (PCP). • UPHP will first contact the PCP to ensure that he or she wants to be designated as the BMP provider.

19. BMP Provider Responsibilities • Coordination of all prescribed drugs, specialty care, and ancillary services • The BMP provider will fill out a UPHP prior-authorization form and check the BMP box if the member needs to be seen by other providers, even if providers are in network.

20. UPHP Prior-Authorization Form

21. All Provider Responsibilities • All Providers MUST verify eligibility before providing service. • BMP members are indicated on the CHAMPS Eligibility Inquiry Response as additional information. • If the BMP Provider Restriction is “Y”, the hyperlink will be activated. • The hyperlink will open the BMP restriction page, which contains the BMP authorized provider information. • If there is no provider listed, the beneficiary is restricted only to the pharmacy refill control mechanism. • Reimbursement for any ambulatory service will NOT be made unless the service was provided, referred, prescribed, or ordered by the BMP provider and a prior authorization is in place.

22. Monitoring and Evaluating BMP Members • Members are placed in the BMP program for a minimum of 24 months. • A needs assessment is done by the Clinical Coordinator involving • The member • Primary care provider • Any and all other parties involved as needed. • The results of the needs assessment will dictate whether the BMP member will be followed through complex case management or care coordination. The Clinical Coordinator will provide updates to the BMP provider and status of member.

23. BMP Contacts at UPHP • Clinical Coordinator: Patty Cornish R.N., M.S.N. • 906-225-7791 • pcornish@uphp.com • Nicole Sandstrom, R.N. Clinical Services Manager, Case Management and Utilization Management • 906-225-7784