A mountain-based health plan is working with Cave Consulting Group, Inc. (CCGroup) in the area of prior authorization and utilization management (PA/UM) transformation. “Over time, an objective is to limit PA/UM programs to outlier providers whose ordering patterns differ significantly from clinically appropriate ranges of clinical practice as well as their peers,” stated Dr. Douglas Cave, President of CCGroup.

Dr. Cave continued, “Outlier providers are identified through the CCGroup Clinical Decision Support System that examines provider performance and adherence to evidence-based medicine.” By specialty type, the CCGroup Clinical Decision Support System examines clinical rows of practice for many medical conditions. A clinical row is comprised of a medical condition, an associated MedMarker™, and an established Clinical MedMarker Protocol Range™.

MedMarkers™ are process of care quality measures, well-defined in clinical guidelines, and also are the key services most associated with cost-of-care in treating a medical condition. Clinical MedMarker Protocol Ranges™ are achievable and clinically appropriate ranges of clinical practice for a MedMarker™. Ranges are developed by presenting the CCGroup National Comparative MedMarker Database™ results to CCGroup National Specialist Panels.

“There are 58 clinical rows to evaluate cardiologists’ clinical practice. Then, depending on the number of clinical rows passed, an objective ‘Pass’ (non-outlier provider) or ‘Fail’ (outlier provider) is assigned to each specialist,” defined Dr. Cave. The CCGroup Clinical Decision Support System objectively Pass/Fail ranks all 50 of the top specialty and sub-specialty types.

The mountain-based health plan also selected CCGroup for the company’s most proven, transparent, and accurate efficiency (cost-of-care) methods and analytics.

Dr. Cave defined, “As well, the health plan will access the Cloud/SaaS-based, CCGroup-CMS Innovator Project results for several mountain states. The CCGroup-CMS Innovator Project provides actionable information on over 80% of all practicing PCPs’ and specialists’ efficiency performance. This information allows the health plan to more accurately stratify, build, and maintain their high value provider network.”

About Cave Consulting Group, Inc. (CCGroup)

CCGroup is a software and consulting firm located in San Mateo, California. The company is focused on improving the efficiency (cost-of-care) and effectiveness (quality-of-care) of the healthcare delivery system. Senior management of CCGroup has assessed the performance of physicians and hospitals for over 30 years for health systems, physician groups, clinically-integrated networks, health plans, HMOs, TPAs, and employers.

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“Outlier providers are identified through the CCGroup Clinical Decision Support System that examines provider performance and adherence to evidence-based medicine.”