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uncompensated care pool
Utilization management programs (UMP) assess the quality, medical necessity, appropriateness of setting, and timeliness of health care services provided in both the inpatient and outpatient acute hospital settings, hospital-based health centers, and community health centers. They can produce significant benefits for patients, providers and payers, including improvements in the appropriateness and quality of the care provided, the appropriateness of the setting in which members receive care, and resource utilization. Through consistent application of the most up-to-date standards of care, UMPs can identify opportunities for process improvement, detect provider education needs, and assess health care services.
Registered nurses perform initial screenings, while board certified, actively practicing, licensed physicians review cases within their specialty areas. Reviewers utilize current practice standards and defined specifications to analyze the utilization of services in order to determine the clinical basis for service delivery, evaluate the timeliness, effectiveness and quality of the services provided, and the appropriateness of the setting in which services were delivered. When indicated, they identify alternative care options and settings.
Specifically, Masspro reviews each UCP case for the following:
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Services were appropriate and delivered in the appropriate setting
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Services provided were medically necessary
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No services were provided for which there is no supporting medical record data
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Claims data is accurate and correct
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Claims submitted for Emergency Room Bad Debt (ERBD) meet the regulatory requirements for emergent services and provider procedures
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Claims submitted for Critical Access Services meet the regulatory requirements
Note: Because the Critical Access Services provision became effective January 1, 2005, only those cases occurring after that date will be included in this review.
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For any outlier case, (length of stay greater than 20 days), each outlier day was medically necessary
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