Peoples Health utilizes an integrated Medical Management Program to coordinate care for plan members throughout the health care continuum and ensure appropriate treatment and coordination of inpatient and outpatient health care services. The program identifies and incorporates methods and tools for coordinating, managing and monitoring all levels of service; proactively manages the utilization of resources; and supports continuity of care to provide medically necessary services and promote optimal treatment outcomes.
The program is not a vehicle for Peoples Health to engage in the practice of medicine or influence the decision-making processes of health care providers. It does not use financial incentives to make or drive medical management or utilization management decisions.
Peoples Health network providers are expected to understand and cooperate with all Medical Management Program components.
Program components and information are provided on the following pages.
Continued participation in the Peoples Health provider network is dependent upon adherence to Quality Improvement and Medical Management Program requirements. Violation of these requirements could include sanctions up to and including termination from the provider network. For more information about the Quality Improvement and Medical Management Program requirements, contact your Peoples Health representative.
Medical Management Medical Necessity Review
Medical management conducts medical necessity reviews as needed to determine the medical necessity of services provided to plan members. These reviews include:
- Prospective review prior to services, including a second opinion, being rendered
- Concurrent review
- Post-stabilization review
Important steps for providers:
- For more effective coordination of care, refer your Peoples Health patients to other providers within their physician team. If a provider specialty is not available in-team, refer patients to a provider in the plan’s network.
- Become familiar with all services that require prior authorization. You can determine if services require authorization by using the Peoples Health Authorization Requirements Search (accessible via the Provider Portal or Peoples Health website) to check procedure codes.
- Submit accurate and fully completed authorization requests. Note: Requests submitted via the Provider Portal are processed quickly; some are automatically authorized at the time of the request. See Tips for Submitting Authorization Requests on the Authorizations tab of Provider Portal.
- Cooperate with discharge planning activities for members in inpatient settings.
Care Management and Social Services
Peoples Health members are periodically stratified utilizing the predictive risk severity within the clinical documentation system. Some of the goals for care management of the higher risk population with complex and multiple health conditions requiring assessment and coordination of resources include:
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- Activities to prevent complications of chronic illness through member education
- Improved access to care
- Improved self-management and independence
- Reduction of acute events
Coordination by social workers identified through referral allows interventions to empower a member or caregiver’s ability to restore social, mental and emotional functioning, as well as ensure continuity of care for members through community resources and social programs.
Care Management
Care management supports the physician, the physician-patient relationship and the patient’s plan of care. Our care coordinator nurses support your Peoples Health patients in complying with treatment plans in the outpatient setting. Care coordinator nurses provide resources for self-care and support for improved outcomes. They provide support for psychosocial issues, and they educate on treatment plans, how to properly follow treatment plans, and how to safely manage care in the home by utilizing additional services, including home health or caregiver services. Care management services also include transplant services to provide support for those preparing for a transplant.
Care coordinator nurses work with patients to identify needs, set goals and help establish a plan of care, which is then monitored. Nurses also help ensure that your patients utilize all plan benefits that can help treat their conditions and instruct in patient self-management of chronic conditions to help reduce readmissions and emergency department visits; prevent complications; and increase the patients’ health care satisfaction to improve health status and quality of life. Care coordinator nurses can provide education to help your Peoples Health patients with:
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- Diabetes
- Heart failure
- Chronic kidney disease, including ESRD
- COPD
- Cardiovascular disease
- Cancer
- Supportive care
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They can also offer educational and resource materials to caregivers of patients with Alzheimer’s disease or dementia.
Care management services may benefit patients that are:
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- Admitted to inpatient care frequently
- In need of assistance with coordination of care for multiple complex health conditions
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Social Services
Our care coordinator social workers work closely with your Peoples Health patients, as well as the patients’ other providers, to identify psychosocial issues that may impact health and independent living status. Our care coordinator social workers work with patients and caregivers to address these issues utilizing health, behavioral health and community resources. They help ensure continuity of care, a proper support system to manage care, and the tools to promote independence, safety and healthy living. They can also help with issues involving housing assistance, food stamps, transportation and behavioral health, as well as those related to access to community programs, utility assistance and financial resources.
Social services may benefit patients who need assistance in managing psychosocial issues that may impact the ability to remain safe, independent and healthy, or who need access to community resources or additional financial assistance to meet basic needs.
Important steps for providers:
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- Refer patients as appropriate to Peoples Health social services or care management services.
- Submit an authorization request.
- Provide supporting documentation for the request (e.g., physician notes, lab results, etc.).
- For the Medical Necessity Form, check Other under the form’s Services Requested section and indicate “refer to care coordinator social worker or care coordinator nurse” as appropriate.
- Indicate the appropriate time sensitivity for service requests.
- Discuss patient needs with the care coordinator.
- Respond to requests for information or recommendations from care coordinator nurses.
- Encourage and reinforce patients’ efforts to manage their diseases and conditions.
- Accommodate appointment requests for patients when care coordinator nurses recommend the appointment.
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Contact our clinical directors for care coordination needs or member concerns.
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- Non-SNP and social worker team: 1-800-631-8443, ext. 2606
- SNP and transition of care team: 1-800-631-8443, ext. 8287
- Clinical programs (Complex Case Management Program, Restorix Wound Home Program, Elara Healing at Home Program, Optum® Cancer Guidance Program): 1-800-631-8443, ext. 1478
How Patients Can Access Care Case Management or Social Services
Our inpatient staff monitors your Peoples Health patients at inpatient facilities (including hospitals, skilled nursing facilities and long-term acute care centers) to determine whether a patient would benefit from these services. Those patients not in an inpatient facility but who have multiple complex conditions may also be targeted for the programs.
Physicians can request services by submitting an authorization request or by calling a Peoples Health clinical director.
Nurse Practitioner Program
Through the Nurse Practitioner (NP) Program, our team of NPs helps facilitate the care management of your Peoples Health patients outside of your office, such as in the patient’s home or at one of our regional service centers. The role of the NP is to:
- Partner with you in providing health education and disease management information
- Provide support to your Peoples Health patients through annual comprehensive wellness assessments
- Facilitate your patients’ access to care as appropriate by following up on annual comprehensive wellness assessments
Patients who meet any of the following criteria are eligible for NP services:
- Have medically complex conditions
- Are chronically ill
- Are frail and elderly
- Require fall prevention assistance
- Were recently discharged from an inpatient facility
- Are in custodial care or confined to the home
To request NP services, discuss the services you are requesting with the patient, then submit your request via Medical Necessity Form. On the Medical Necessity Form, check Other under the form’s Services Requested section, and describe the list of needs to review.
Upon receipt of your request, a representative will contact your office to review it. For approved services, our NP will meet with your patient to conduct an evaluation or provide the needed services. We will fax a clinical progress note of the NP’s assessment to your office and we may call you to follow up.
Reference Section B.2 (Physician Administrative Information) of this guide for information about utilizing NPs in your office. For questions about requesting NP services, please call the clinical health services department at 1-866-855-7328, Monday through Friday, from 8 a.m. to 5 p.m.