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24 11/2005
Over and Under-Utilization
We do recognize opportunities for under and over-utilization and appreciate the
negative impact this has on the quality of health and care for our members. With this
in mind, the annual UM program does include on-going activities including review of
practice patterns and profiling data along with clinical guidelines in order to detect
patterns of under and over utilization and to consider activities to address these
issues and correct any identified patterns.
Case Management
BCBSGa provides case management for catastrophically ill or injured members who
require extensive medical services and who have exceptional or complex needs.
Eligibility for the case management program is determined on a case-by-case
basis by BCBSGa. The case management programs will help guide members
requiring support through difficult illnesses.
Cases are identified for potential case management from internal and external
sources to include but not limited to UM authorizations, physician referrals, Health
Improvement Programs, claims data and from members and their families. Case
managers will assess the members’ needs, determine benefits available to address
the members’ needs and establish a treatment monitoring plan in collaboration
with the various healthcare providers and member. Case managers may also
explore extra contractual benefits for complex situations if they will promote
appropriate and cost-effective care.
Emergency Services Utilization
Emergency room usage by members is available for emergency situations. PCPs are
required to have 24-hour, seven-days-a-week call coverage to assist the member,
and ensure they receive care at an appropriate facility. Routine care for non-life
threatening conditions should not be directed to the ER unless no other options exist.
If a member or provider deems a medical condition potentially life or limb
threatening, the member should be directed to the nearest/most appropriate ER.
The PCP must notify BCBSGa within 48 hours of the referral to the ER. BCBSGa
decision to cover ER services, whether in or out-of-network ER facilities, will be
made in accordance with prudent layperson legislative provisions. BCBSGa will