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 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
servicesDrug interactionsPossible drug abuse
Modify the member’s improper 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 evidenced-based practices, thereby curtailing unnecessary costs to the program.
BMP Program Functions
IdentificationWho is misusing or overutilizing services?
EvaluationAre services utilized appropriate for members?
EducationDoes a member understand appropriate benefit utilization?
MonitoringAre interventions working?
Identification of Potential BMP Candidates
State IdentificationPROM (PROgram Monitoring)system
UPHP Member IdentificationMember comes on the plan already in the BMP program. Identified by internal utilization review.
Possible fraud? Overutilization of services or medications?
Provider Identification
BMP Enrollment Criteria
Criteria for beneficiaries to be placed in the program include:FraudInappropriate use of emergency department servicesInappropriate use of physician servicesInappropriate 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 impersonationUsing 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 quarterRepeated 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 CategoriesNarcotic AnalgesicsBarbituratesSedative-Hypnotics, Non-
BarbiturateCentral Nervous System
Stimulants/Anti-Narcoleptics
Anti-AnxietiesAmphetaminesSkeletal 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 concernsThe 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 NotificationThe 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-for-Service 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: 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 servicesDental servicesServices rendered by a
nursing-facility providerServices rendered in an
inpatient hospitalHospice servicesVision services
Services rendered at a local health department
Hearing servicesPodiatry servicesChiropractic servicesServices rendered by a non-
prescribing 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 ResponsibilitiesCoordination of all prescribed drugs, specialty care, and
ancillary servicesThe 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. 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
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., [email protected]
Nicole Sandstrom, R.N. Clinical Services Manager, Case Management and Utilization Management906-225-7784