Virginia Medicaid aims to continue cost-containment
Cost-effectiveness and quality of care "are some of the key elements of the Virginia Medicaid program," according to Cheryl Roberts, deputy director of the state's Department of Medical Assistance Services (DMAS).
Ms. Roberts adds that in light of the current economic climate and growing demands placed on the Medicaid program, "we will not only continue these initiatives but enhance them to control costs, as well as increase our effectiveness."
Here are some of the programs DMAS has implemented to help deliver services in the most cost-effective manner:
Claims control initiatives.
ClaimCheck software (manufactured by McKesson Health Solutions) is used to prevent improper payments when incorrect claim code combinations are reported. All physician and laboratory claims are subject to the ClaimCheck edits, which are invoked if the same recipient, same provider, and same date of service is entered.
In the event an incorrect code combination is found, ClaimCheck will either deny one of the codes or "re-bundle" the code combination and create a claim for the correct procedure. "These edits assure that the providers are billing DMAS correctly, based on appropriate billing guidelines," says Ms. Roberts.
Along with the ClaimCheck editing software, DMAS also has other claims processing system edits. "Edits are in place to prevent duplicate payments of claims, to assure the claim is paid at the correct rate, and to assure the procedure codes are valid," she reports. Claims also are reviewed manually, such as emergency department claims and out-of-state hospital claims, to ensure medical necessity.
Prior authorization.
This process approves specific services for an individual enrolled in the Medicaid Family Access to Medical Insurance Security Plan (FAMIS) and FAMIS Plus (children's Medicaid) by a Medicaid-enrolled provider, prior to service delivery and reimbursement.
"The primary objective of the prior authorization function is to serve as a utilization management measure, allowing payment for only those services that are medically necessary, appropriate, and cost-effective," says Ms. Roberts.
Prior authorization does not guarantee payment for the service. Payment is contingent upon passing all edits contained within the claims payment process, the individual's continued Medicaid eligibility, the provider's continued Medicaid eligibility, and ongoing medical necessity for the service.
Prior authorization is specific to an individual, a provider, a service code, an established quantity of units, and for specific dates of service. Requests that are pending for additional information or denied for not meeting medical criteria are automatically sent to professional medical staff for review.
When a final disposition is reached, the individual and the provider are both notified in writing of the status of the request. If the decision is to deny, reduce, terminate, delay, or suspend a covered service, written notice will identify the recipient's right to appeal the denial. "The provider also has the right to appeal adverse decisions to the department," says Ms. Roberts.
Pharmacy initiatives.
The Medicaid program uses a Preferred Drug List (PDL), which allows payment without requiring prior authorization. "The major goal is to reduce the use of more expensive drugs to treat patient illnesses, when alternative medications are available that provide the same therapeutic benefit but at a lower price," says Ms. Roberts.
The PDL program establishes a formulary for select therapeutic drug classes with prescription drugs that have the same clinical effectiveness, but whose manufacturers have agreed to sell their products to the state's Medicaid program at a lower price.
"This allows DMAS to generate savings in its prescription drug program, while ensuring that Medicaid patients have continued access to drugs which have a proven efficacy," says Ms. Roberts.
The pharmacy dose optimization program identifies high-cost products where all strengths have the same unit cost and the standard dose is one tablet per day. By providing the highest-strength daily dose, the number of units in a 34-day supply is minimized.
The RetroDUR (Drug Utilization Review) program examines medication history to identify certain patterns of use. After a computer analysis of claims data, an expert panel of reviewers evaluates a sampling of records. In appropriate circumstances, patients are sent educational intervention letters. "These are customized to each identified case and mailed by the program contractor," says Ms. Roberts. "Letters may be sent to both patients and prescribers, depending on the specifics of each case."
ProDUR is an interactive online, real-time process in which pharmacy claims are evaluated during the claims submission process. "Potential problems related to the established criteria generate an immediate alert message to the pharmacist," she explains.
Cost-effectiveness and quality of care "are some of the key elements of the Virginia Medicaid program," according to Cheryl Roberts, deputy director of the state's Department of Medical Assistance Services (DMAS).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content