Buckeye Community Health Plan does not reward practitioners, providers or employees who perform utilization reviews, including those of the delegated entities. No one is compensated or otherwise given incentives to encourage denials.
Utilization denials are based on lack of medical necessity or lack of covered benefit.
Buckeye and its delegated health plan partners have utilization and claims management systems in place in order to identify, track and monitor the care provided and ensure appropriate healthcare is provided to members.
Buckeye has implemented the following to ensure appropriate utilization of healthcare:
- A process to monitor for under- and over-utilization of services and initiate the appropriate intervention when identified.
- A system in place to support the following processes:
- Analysis of utilization statistics.
- Identification of potential quality of care issues.
- Processes to implement intervention plans and evaluate the effectiveness of the actions taken.
- A process to support continuity of care across the healthcare continuum.