“Exception” reports are regularly generated for Health Net management review. If the manager identifies practice patterns that suggest variance from clinically accepted guidelines, these practitioner/member combinations are assigned to a licensed Utilization Manager for clinical review. The Utilization Manager does a full review of case notes and member history to better understand the clinical situation and history of treatment. If, based on the clinical aspects of the case, the Utilization Manager decides that no further intervention is required, they will consider the review complete. If further discussion is indicated, they will contact the practitioner for a discussion of the member’s clinical status, current signs and symptoms, the practitioner’s goals and milestones of treatment, and how the current treatment plan is designed to meet these goals.

Health Net has found that in most cases, practitioners are very open to a collegial, collaborative discussion and often will accept the Utilization Manager’s offer of assistance; for instance, to arrange for a medication evaluation, or an adjustment in the treatment plan with an agreement to review again at a later, mutually established time.

In those infrequent cases in which there are ongoing concerns after contacting the provider, the Utilization Manager will consult with a Health Net medical director to determine the next steps. Health Net has found that due to this collaborative process with practitioners, a need for further corrective action is rarely required. Overall, this process has been very well received by the provider community.