Benefits Monitoring Program

To ensure that the appropriate amount, scope, and duration of medically necessary services are provided to Upper Peninsula Health Plan members, UPHP will now conduct surveillance and benefits utilization review, known as the Benefits Monitoring Program (BMP). The BMP is in place to closely monitor program usage and to identify members who may be overutilizing or misusing their UPHP Medicaid services and benefits.

The purpose of the Benefits Monitoring Program is to:

  • Promote high-quality health care.
  • Prevent harmful practices such as duplication of medical services, drug interaction, and possible drug abuse.
  • Identify members for review who may misuse or overutilize their Medicaid benefits.
  • Analyze member patterns of utilization of health services.
  • Modify a 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 evidence-based practices, thereby curtailing unnecessary costs to the program.

Members are enrolled in BMP when UPHP determines any of the following (alone or in combination) criteria apply to an individual:

  1. The member is suspected, or has been convicted, of fraud, such as altering prescriptions to obtain medical services, products, or pharmaceuticals.
  2. The member is misusing emergency-department services, such as going to the emergency room for non-emergent conditions.
  3. The member is misusing pharmacy services, such as utilizing more than three different pharmacies in one quarter.
  4. The member is misusing physician services, such as obtaining duplicate or similar services from more than one physician or physician extender in different practices.

UPHP will also review additional criteria as misutilization patterns emerge or are identified by the plan.

If you think that one of your patients is a candidate for the BMP program, call Customer Service at 800-835-2556 or fill out the Care-Coordination/Case-Management Referral Form.

To view the 2013 BMP Provider In-Service slides, please click here.

 


Page Last Updated: 09/30/2016