Transcript No Slide Title

Benefits Monitoring Program
(BMP)
Upper Peninsula Health Plan
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.
Purpose of the Program
 Promote high-quality health
 Modify the member’s improper
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
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 evidencedbased practices, thereby
curtailing unnecessary costs to
the program.
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?
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.
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Possible fraud?
Overutilization of services or medications?
 Provider Identification
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
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
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
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, NonBarbiturate
 Central Nervous System
Stimulants/AntiNarcoleptics
 Anti-Anxieties
 Amphetamines
 Skeletal Muscle Relaxants
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.
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.
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)
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
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.
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-forService Medicaid, provided that member remains a
Michigan resident.
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:
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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.
Exempt Services
 The following services may
be exempt from the BMP
Control Mechanisms:
 ED services
 Dental services
 Services rendered at a local
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 Services rendered by a
nursing-facility provider
 Services rendered in an
inpatient hospital
 Hospice services
 Vision services

health department
Hearing services
Podiatry services
Chiropractic services
Services rendered by a nonprescribing mental health
provider (e.g., MSW’s,
P.h.D.s, professional
counselors, etc.)
STI screening and
treatment, family planning,
and related services
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.
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.
UPHP Prior-Authorization Form
All Provider Responsibilities
 All Providers MUST verify eligibility before providing service.
 BMP members are indicated on the CHAMPS Eligibility Inquiry
Response as additional information.
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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.
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
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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.
BMP Contacts at UPHP
 Clinical Coordinator: Patty Cornish R.N., M.S.N.
 906-225-7791
 [email protected]
 Nicole Sandstrom, R.N. Clinical Services Manager, Case
Management and Utilization Management
 906-225-7784