United States Marshals Service's Prisoner Medical Care
Report No. 04-14
Office of the Inspector General
The purpose of the proposed contract is to: 1) establish a nationwide integrated health care delivery system, including Preferred Provider Networks (PPN);43 and, 2) process and pay medical claims consistent with the Medicare and/or Medicaid payment standards required by 18 U.S.C. §4006 as amended. A managed health care system would include negotiated contracts with medical facilities and providers, claims processing and payment, utilization review and quality management.
Managed Care Network
The contractor would be required to establish a managed care network with community physicians, hospitals, and other ancillary services. These services provided to USMS prisoners would include dialysis, pharmacy discounts, optometry, ambulance, dental, skilled nursing facilities, and outpatient rehabilitation.
Also the contract would ensure that emergency services are available within each network site 24 hours a day, 7 days a week. Those services would be available at the hospitals or emergency care facilities that support the USMS's major use detention facilities.44
The contractor would be required to incorporate USMS Prisoner Health Care Standards, USMS administrative procedures, financial terms and rates, hospital affiliations, and USMS security requirements into all PPN provider agreements.
In some cases the PPN provider may choose to refuse to accept the provisions of Public Law 106-113 (Medicare or Medicaid). If the contractor determines that the particular provider specialty is essential the contractor should be required to have the provider agree to accepting rates approved by the USMS.
A national health care contract will also enable the USMS to obtain preferred pricing45 which will result in additional savings over and above the USMS allowed amount (Medicare or Medicaid).
Once the USMS allowed amount has been determined for each claim, the contractor will then review each claim to identify any additional savings that could be generated through preferred pricing. For example, a medical procedure is billed at $10,000, but the Medicare rate for this claim is $8,500. However, due to preferred pricing, the contractor is able to reduce the amount to be paid by the USMS to $5,000.
In that case, the preferred pricing amount ($5,000), not the billed amount or the Medicare rate, is determined to be the lesser amount and the revised USMS allowed amount. In the instance cited savings for the USMS above the Medicare amount would be $2,500, less a percentage paid to the contractor for the cost savings provided.
The OIMS believes that the national health care contract would reduce USMS prisoner medical expenses by obtaining preferred pricing rates below Medicare or Medicaid, pharmacy discounts and other reduced rates.
Centralized Medical Claims
The contractor would be required to establish an automated centralized medical claims system to process and re-price valid claims for medical care and supporting medical services provided to USMS prisoners in accordance with USMS allowed amounts.
The following is a listing of tasks and responsibilities that should be shared by the contractor, district office and the Office of Interagency Medical Services (OIMS) required to authorize, pay and manage prisoner outside medical claims.
Utilization Review Program
The Utilization Review (UR) program is designed to foster access to appropriate, quality and cost effective care for USMS prisoners. The review involves the assessment, evaluation, planning and implementation of health care services. The UR program provides a formal process that promotes objective, systematic monitoring and evaluation of appropriate resources throughout the continuum of care.
Concurrent review is an assessment of on-going medical services to determine continued medical necessity and appropriateness of care. Case management is a process for the management of chronic medical/behavioral health conditions that includes unexpected catastrophic occurrences, as well as proactive management of anticipated medical management situations. Discharge planning is the coordination of a patient's continued care needs when discharged from the inpatient setting.
The OIMS is responsible for examining the utilization of inpatient services to assess medical necessity and appropriateness. As part of the concurrent review function, the OIMS should monitor and track the length of stay for all inpatient admissions. The contractor's database and website would provide direct automated support to OIMS to enable them to carry out this function.