Identify Medical Appropriateness Guidelines Project Description: Criteria used for utilization management purposes are often derived from nationally published practice guidelines/recommendations.

Healthcare Quality Management Student Workbook – 5th edition Project 8-2: Identify Medical Appropriateness Guidelines Project Description: Criteria used for utilization management purposes are often derived from nationally published practice guidelines/recommendations. In this project you’ll locate treatment recommendations relevant to a particular patient population and interpret the recommendations. Instructions 1. Presume you are the quality manager in a general surgery outpatient clinic. The business office manager comes to you with a reimbursement problem. A health plan has denied payment for three claims involving drainage of non-painful fluid-filled breast cysts in female patients. All are patients of a surgeon who recently moved from another state and joined the clinic nine months ago. The other clinic physicians do not routinely drain non-painful breast cysts that are confirmed by ultrasound as harmless fluid filled sacs. The new physician says that in her experience drainage of these cysts help relieve patients’ anxiety and fear the lesion could become cancerous. The business office manager doesn’t know how the surgeon should respond to the payment denials and asks you to research appropriate treatment options for patients with non-painful fluid-filled breast cysts. 2. Locate the most recently published practice guideline for treatment of patients with non-painful fluid- filled breast cysts. 3. Obtain a complete copy of the most recent guidelines. Write a memo to the business office manager to share with the surgeon that includes the following information: a) Group that published the guideline b) Year the guideline was published c) Where the guideline can be found online (site name and URL) d) Based on the guideline recommendations: . Is drainage an appropriate treatment for patients with a non-painful fluid-filled breast cyst? Are there any circumstances that might make this treatment appropriate? Should the surgeon challenge the insurance payment denials or not? If yes, how should the challenge be worded? If no, how should the surgeon change her practices going forward? Is there something she can do differently to comply with the guidelines?