Medical Management Program Audits

HDM reviews the medical management services of plan administrators to measure and assess program protocols and processes and ensure that 1) case management is efficient and 2) the program produces intended outcomes.

We measure total membership participation in the case management program during the audit period, and the opportunities for increasing member participation.

HDM also reviews files and tests the evaluation criteria to determine the process for engaging and administering care as part of medical management, and determine if it was handled correctly. Each case is evaluated against the following criteria:

• Criteria for opening case
• Oral consent documented
• Written consent documented
• Nature of relationship explained to member
• Permission to share information with other parties
• Complaint process explained to member
• Rationale for case management made available to member
• Assessment documented
• Plan of care documented
• Evidence of collaboration with member’s physician
• Short-term goals documented
• Long-term goals documented
• Resource list to member
• Collaboration with Patient Evidence
• Termination Criteria Documented at Discharge

To discuss how HDM’s cost containment solutions for self-insured employers can benefit your organization, contact HDM today at 800.859.5119 ext. 1 or e-mail your inquiry to: info@HDMinc.com.