Medicaid Fee-For-Service Utilization Review Program

MPRO has provided prospective and retrospective utilization review services for the Medicaid Fee-for-Service (FFS) population for the Michigan Department of Community Health (MDCH) since 1988.
MPRO provides utilization review and audit services for MDCH.

The Prior Authorization Certification Evaluation Review (PACER) Program

PACER conducts elective inpatient admissions, inter-hospital transfers, readmissions and rehabilitation admission and continued stay reviews.

Learn more about PACER

• Pacer Retrospective Review Form (PDF)

• Pacer Retrospective Review Form (MS Word)

 

The Emergency Room/Outpatient and Inpatient Audit

The audits are a targeted review program that evaluates a sample of medical records for a specific provider. MDCH randomly selects providers from the emergency room/outpatient setting and the inpatient acute care/acute rehabilitation setting. MPRO’s registered nurses and a support team make arrangements to scan the provider’s medical records in accordance with MDCH guidelines. An audit is conducted of the scanned records at MPRO’s office and a report is submitted to MDCH upon the completion of the audit. MDCH notifies the provider of the audit results.

Long Term Care Determination

A concurrent review is conducted telephonically. The review is to determine if the Medicaid beneficiary meets state criteria to enter/remain in a medical reimbursement nursing facility or a community-based waiver program for the elderly or disabled. Retrospectively, MDHC randomly selects a sample of beneficiaries that have received services in a nursing facility or community-based waiver program. Upon receipt of the medical information, MPRO validates that the beneficiary was eligible to receive care in the nursing facility or community-based waiver program. MDCH verifies/confirms eligibility in three programs: Nursing facility, MI Choice and PACE (Program for All-Inclusive Care of the Elderly).

Statewide Utilization Review Program

This program evaluates randomly selected medical records from each acute care/acute rehabilitation provider in Michigan. The provider is sent a case listing of medical records that need to be submitted to MPRO. Upon receipt of the medical records and continued stay for rehabilitation providers, the cases are evaluated for the medical necessity of the inpatient admission and the appropriateness of DRG coding. Currently, this program’s focus is to educate Michigan providers on MPRO’s review findings.

• Pacer Program
• Resources
• Michigan Department of Community Health