Core Clinical Management and Monitoring

​​​​Cardinal Innovations uses several clinical tools to ensure funded services are being appropriately utilized and are of high quality. These tools include prior authorization (PA), tracking of under/over utilization, as well as quantitative and qualitative measurements of clinical quality. It is vital that Cardinal Innovations members receive care that is medically necessary, in the right amount, for the right duration, and in the least restrictive setting. All these monitoring and management tools help ensure these goals are met.

Prior Authorization

Prior authorization (PA) means that Cardinal Innovations requires a Treatment Authorization Request (TAR) be submitted prior to a service being provided so that medical necessity can be adequately assessed. PA is required in the following kinds of instances:

  1. High cost and highly restrictive services (ACTT, CST, IIH, Day Treatment, Residential, Inpatient, PRTF)

  2. Low cost, minimally restrictive services being used in amounts that are greater than community norms (outpatient therapy, psychological testing)

  3. Individual Support Plans (ISPs) for consumers in Innovations.

  4. Non-entitlement services (IPRS-State Funded Services) where funding sources are strictly limited.

Over/Under Utilization Tracking

Cardinal Innovations reviews claims data and compares those data to expected norms to look for indications of over- or under-utilization. The goal is to identify instances when services are used too infrequently to be effective, or too often such that either a different level of care may be indicated, or low quality of care may be being delivered. Also, Cardinal Innovations reviews coding to ensure providers are not over or under coding for specific services. Examples of over/under utilization data include the following:

  1. Length of stay

  2. Rates of use of add-on/crisis codes

  3. Rates of use of basic/crisis services for enhanced or residential level services

  4. Units/Sessions used per unit of time (compared to peer benchmarks)

  5. Member engagement in services (units/sessions used toward the beginning of a service)

Quantitative Clinical Data Monitoring

Quantitative claims, authorization and other data can be a proxy indicator of clinical quality. Cardinal Innovations reviews certain types of data to assess provider quality and patient safety. These types of data include the following:

  1. Rates of crisis system use

  2. Readmission rates at various time intervals

  3. Prescribing practices

  4. Total cost of care (Medicaid only)

  5. LOCUS/CALOCUS/ASAM match with level of care requested/provided

Qualitative Clinical Data Monitoring

Certain aspects of clinical quality can only be obtained by manually reviewing member medical records. This kind of data is gathered through two types of reviews:

  1. Quality Management (QM) Monitoring can be performed on a routine (regularly scheduled) or focused (problem-based) basis. From a clinical standpoint, QM audits look at compliance with the following:

    1. Statutory regulations

    2. Medicaid and State Service definition and Clinical Coverage Policy requirements

  2. Utilization Management (UM) audits are called utilization review (UR), which is a tool Cardinal Innovations uses to evaluate certain aspects of the clinical quality of the services it funds. A UR can be routine, where all providers of a specific service are reviewed, or focused, where a specific provider is reviewed because of concerns about quality of care. While each service will require service-specific questions, most URs evaluate clinical quality by reviewing the following aspects of care:

    1. Diagnostic Integrity (comprehensiveness of symptom evaluation and diagnostic accuracy)

    2. Appropriateness of level of care (medical necessity)

    3. Effective Coordination of Care and Communication with other providers and/or invested parties

    4. Appropriate discharge planning and referrals

    5. Use of and fidelity to Evidenced-Based/Best Practices and Clinical Guidelines

    6. Measurement/Evaluation of progress (e.g., use of "treat-to-target")

    7. Adequacy of informed consent and respect for patient rights

    8. Compliance with service definitions (staffing, documentation, service provision)

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