The Utilization Review Program promotes appropriate
allocation of the academy's resources by striving to provide quality
patient care in the most cost-effective manner.
Authority:
The Board of Directors of American Academy of
Micropigmentation agrees that our micropigmentation healthcare resources
and practitioner services must be utilized efficiently while assuring
quality care for all patients. The Board of Directors has delegated
the responsibility and authority for achieving this goal to the
academy's Administration and Medical Staff. The Utilization Review
Committee has been established by the academy's Bylaws (Article
XII, Section 1, Paragraph K). This committee will oversee all Utilization
Review activities and report these quarterly to the Quality Assurance
Committee.
Organization of Committee:
The committee will meet at least annually. The
Utilization Review Committee shall consist of at least four (4)
Fellow members appointed by the President of the AAM for a term
of one (1) year.
In addition, there will be four (4) non-voting,
members appointed by the President. Other non- practitioner, non-voting
members may be appointed at the discretion of the Chairman. Fifty
percent of the voting members of the committee shall constitute
a quorum (Bylaws Article XIV, Section 4). Minutes of the utilization
Review Meetings are forwarded to and reviewed by the Board of Directors.
Conflict of Interest Statement:
Any person who holds investment in any micropigmentation
company where his ownership interest is in violation of regulations
on investment interests is not eligible for appointment to the committee
or to participate in any Utilization Review activities.
Program Responsibilities:
Functioning under Federal and State regulations
and under guidelines established by the Joint Commission on Accreditation
of Healthcare Organizations and the Academy Bylaws, the Utilization
Review Committee will:
1. Strive to make sure that Academy services provide
to patients are medically necessary, are provided at the appropriate
level of care and are in accordance with professionally recognized
standards of quality.
2. Recommend changes in Academy procedures as
indicated on analysis of review findings in order to address over
utilization, underutilization, and inefficient use of resources.
3. Promote close liaison and distribute all communications
with any Federal or State agency as required by applicable status
and regulations.
SCOPE OF UTILIZATION MANAGEMENT:
Methods of Review:
All decisions made by the Committee and its representatives
will be based on criteria, standards and norms adopted or developed
by the Committee and approved by the Executive Committee of the
Acadmey's Board of Directors. All actions with respect to reviews
are documented.
Treatment Reviews:
Treatment Review meets criteria of failure to
meet criteria proposed procedure(s)
The Utilization Review is consulted for the following:
Any change in patient's condition or change in treatment schedule
or any questionable extended treatments. The Consultant consults
the practitioner for his input. In the event an adverse determination
is rendered by the Consultant, a second review will be performed
by another Consultant within one (1) month. If denied by both reviewers,
denial notices will be distributed in accordance with committee
established policy and/or federal statute rules to the patient and/or
patient representative, practitioner, and the relevant financial
intermediary.
Reconsideration requests must be in writing and
filed within 30 days of the initial determination to the Board of
Directors of the AAM. Each reconsideration appeal must be in writing
and filed within 30 days of initial determination and is reviewed
by the Utilization Review Committee.
QUALITY CONTROL STUDIES:
The scope of Utilization Review includes the data
collection in special quality control studies. These studies will
be defined by the Utilization Review Committee and performed by
the Utilization Review Coordinator(s). The studies may include,
but are not limited to: care evaluation studies, and general and
support service functions. A minimum of one (1) care evaluation
study will be completed annually and reported to the Utilization
Review Committee and others in accordance with Academy Quality Assessment/
Improvement Plan.
Confidentiality Statement:
All information and data utilized and generated
by the committee is kept confidential. The committee is responsible
for maintaining confidentiality of patient/medical staff information
and safe-guarding that data against loss, Utilization Review data
is limited. Outside agencies such as the FDA Commission on Accreditation
of Healthcare Organizations, and other business healthcare coalitions
may have a right to see this data through special agreements with
the Academy.
Fraud and Abuse:
The committee operates in accordance with Federal
Regulation, Section 1160 of the Social Security Act.
Evaluation Mechanism:
The Academy's Utilization Review Program is reviewed
and evaluated at least annually and revised as appropriate to reflect
the findings of the Academy's Utilization Review activities.
