Right Choices Program
A combined MCO Presentation
HP IHCP Provider Seminar
October 20, 2010
Indianapolis Marriott East
An independent licensee of the Blue Cross and
Blue Shield Association
RCPP0001 (09/10)
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Right Choices Program
Presented by
Kelly Henderson, PharmD, RPh
Director of Clinical Programs
MDwise, Inc.
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Overview
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History
Program Overview
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Identification of member
Primary Care Physician- Medical Home
Program Specifics
Review of waivers
Care Management as a tool
Claims submission requirements
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History of Program
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HealthCare Excel (HCE) began
SURS unit that developed original
Restricted Card Program for IN
RBMC MCOs were first allowed to
participate in 2005 via a HHW pilot
program
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Right Choices Program is Different -experiences gained in the pilot and
availability of managed care resources
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What is the Right Choices Program?
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The Right Choices Program (RCP) is
a program that identifies members
appropriate for assignment and
subsequent “lock-in” to:
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one Primary Care Physician (PCP)
one pharmacy and
one hospital
“Lock-in” periods start at 5 years
and a member is evaluated as early
as 2 years to see if they are ready
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to be released.
Member Identification Process
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members are considered candidates for restriction if
they continue to misuse their benefits despite efforts
on the part of RCP Administrator and its provider(s) to
educate and assist the member in modifying misuse
patterns.
The RCP Administrator considers multiple factors in
enrolling a member into this program. They include,
but are not limited to:
 Emergency Room utilization
 Medical records review
 Pharmacy utilization
 member compliance history
 outcomes of member interventions
 care management activities
 referrals from providers
 referrals from other internal and external sources
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Primary Care—Medical Home
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Right Choices Program reinforces the concept of the “Medical
Home”.
 The member can no longer receive medical care and fill
prescriptions outside of the medical home without the
Primary Care Provider (PCP) being made aware and
involved.
 Pharmacists are strongly discouraged from allowing
Medicaid Right Choice members to pay cash for
medications.
 In some cases, depending on the prescription, this
action may be interpreted as the pharmacist’s
willingness to “aid or abet an addiction” or knowingly
support diversion of a controlled substance
 Non-emergent use of the ER is not a covered service
 Payment is the responsibility of the member
 ER must have member complete a waiver—CMS
requirement
 ER should educate member about proper
utilization of services
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Getting a Member Approved for RCP
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Incoming referrals or claim data support further
review of member’s utilization pattern
Care manager (CM) alerted of referral or data
Care manager begins working with the member
and/or providers and “builds a case” if necessary
by documenting utilization patterns and attempts
made by the care manager and/or providers to
intervene or guide the members utilization
choices
member resists interventions, PCP and CM agree
to pursue RCP as an additional care management
tool
Case file is forwarded to clinician for review and
consideration for placement into RCP Program
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Getting a Member Approved--continued
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Clinician reviewer considers the
case file in its entirety. In addition,
they rule out clinical issues that
may explain overutilization:
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Pseudoaddiction
Catastrophic chronic illness
Unidentified psych diagnosis
PCP already primary prescriber
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Notification to Providers
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Once a member is active in the program,
the PCP, lock-in hospital and lock-in
pharmacy are notified in writing and given
clear instructions.
In addition, the Member’s eligibility is
flagged for ALL IHCP providers.
 So that ALL providers will be aware of
the restriction and not render nonemergent services without first obtaining
a member waiver to accept financial
responsibility for services rendered.
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The RCP Medical Home
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The PCP is responsible for coordinating all
aspects of the RCP members’ care.
RCP Administrator will support PCP and
help PCP oversee
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Care manager- present throughout the entire
enrollment in the program
Care manager-must receive written referrals
from PCP if RCP member is to be seen by
another provider
 RCP Administrator will process written
referrals so that corresponding claims are
recognized and accepted for payment by HP
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Written Referrals
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Referrals are encouraged to be kept to a minimum. Too many
referrals allow for members to see multiple providers at will and
potentially circumvent the RCP program
 Residency programs are NOT considered ideal for RCP
members
Referral requirements:
 The PCP must write the referral on the PCP’s letterhead
or prescription pad (provider NPI, phone, address,
specialty, rationale)
 The PCP must date and sign the referral (electronic
signature is ok)
 The referral must include the member’s name and
member id
 The referral must include the specialist’s first and last
name
 The PCP should list the period for which the referral is
valid. If no time period is specified on the referral, the
referral will be applied for the duration of the
restriction.
 It is preferred that a reason for the referral also be
communicated for care management support
Note: It is important to remember that HP/RCP Administrator
does not reimburse providers for services unless these guidelines
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are followed because these services are non-covered.
Appropriate ER utilization
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Important to reinforce that the ER is not an ideal
“Medical Home” AND that ER is often sought when
a members PCP “won’t give them what they want”
Check eligibility in ER and RCP enrollment Status,
communicate to ER staff (also use INSPECT)
Emergent claims will be reimbursed by HP without
authorization from the Right Choice Program
member’s PCP.
It is important that ERs follow this procedure in
order for inappropriate ER use to be deterred and
for the Right Choice Program to have its best
outcomes.
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Financial Responsibility of RCP
Member
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The Right Choice Program member is responsible
for payment of services if the member chooses to
receive services from providers for whom they are
not authorized to receive service.
Prior to rendering the service, the provider must
inform the Right Choice Program member orally
and in writing that the service is non-covered.
The member may elect to request a written
referral from their PCP OR sign a waiver and
accept financial responsibility for the services
rendered.
Note: For more information on billing IHCP
members, refer to Chapter 4, Section 5.
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RCP Support
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The member’s assigned care manager is responsible for
 communication
 monitoring
 managing a member’s care plan
 coordinates all aspects of the member’s restrictions
 monitoring emergency room use
 pharmacy utilization patterns
 collaborating with the member’s assigned pharmacy
and PCP
 updating the care plan as necessary
 coordinating behavioral health care plans
 continuity of care.
At regular intervals, member compliance is monitored
 reviewing treatment plans
 utilization of services
 care coordination conferences between the member, and
the member’s care manager. The member’s PCP and
Pharmacist will also be involved from time to time in care
conferences.
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RCP Support
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At the end of a member’s RCP enrollment period, a
decision to remove the member from the RCP may be
made based on member compliance with the program
and their treatment plan. The PCP, lock-in pharmacist,
and Care Manager review the case and make
recommendations for continuation or release from the
program
If a Right Choice Program PCP encounters any issues
that may affect the care of a RCP member, the PCP is
STRONGLY encouraged to contact the member’s care
manager in efforts to coordinate a meaningful
intervention. URGENT Care Conferences can be
arranged.
RCP Administrators supports its PCPs participating in
the Right Choices Program. Please involve us if you
need additional assistance in dealing with a member.
Providers should contact the member’s care manager
with questions regarding that member’s participation in
the RCP.
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Thank You
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From the MCEs
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