Minnesota Restricted Recipient Program (MRRP)

The purpose of the MRRP is to identify PrimeWest Health members who have used services at a frequency or amount that is not medically necessary and/or who have used health services that resulted in unnecessary costs to the program. Once identified, such members will be placed under the care of a primary care physician and/or other designated providers who will coordinate their care for a 24-month period.

Investigation

The PrimeWest Health RRP team conducts investigations to determine if:

  1. A fraud, theft or abuse situation exists and can be supported by documentation;
  2. Sufficient justification exists to support restricting a member to a primary care physician and/or other designated providers; and/or
  3. Sufficient evidence exists to support the imposition of other sanctions.

Abuse: In the case of a member, the use of health services that results in unnecessary cost to PrimeWest Health or in reimbursement for services that are not medically necessary. The following practices are deemed to be abuse:

  1. Obtaining equipment, supplies, drugs, or health services that are in excess of PrimeWest Health limitations, or that are not medically necessary and that are paid for by PrimeWest Health
  2. Obtaining duplicate services for the same health condition from multiple providers. Duplicate service does not include an additional opinion that is medically necessary for the diagnosis, evaluation, or assessment of the member’s condition or required under PrimeWest Health rule, or a service provided by a school district as specified in the member’s individualized education plan under MN Stat. sec. 256B.0625, subd. 26.
  3. Continuing to engage in practices that are abusive of the program after receiving a written warning from PrimeWest Health that the conduct must cease
  4. Altering or duplicating the PrimeWest Health ID card for the purpose of obtaining additional health services billed to PrimeWest Health
  5. Using a PrimeWest Health ID card or ID number that belongs to another person, or allowing others to use their PrimeWest Health ID card or ID number to obtain services, drugs, or equipment
  6. Using the PrimeWest Health ID card to assist an unauthorized individual in obtaining a health service for which PrimeWest Health is billed
  7. Duplicating or altering or falsifying prescriptions
  8. Misrepresenting material facts as to physical symptoms for the purpose of obtaining equipment, supplies, health services, or drugs
  9. Furnishing incorrect eligibility status or information to a provider
  10. Furnishing false information to a provider in connection with health services previously rendered to the member that were billed to PrimeWest Health
  11. Obtaining health service by false pretenses
  12. Obtaining health services that are potentially harmful to the member
  13. Repeatedly obtaining emergency room (ER) health services for non-emergency care
  14. Using medical transportation to obtain health services from providers located outside the local trade area when health services are available within the local area
  15. Repeatedly canceling services at one provider and getting them from a different provider to avoid paying a spenddown

Grounds for Sanctions against Members

The PrimeWest Health RRP team may impose administrative sanctions against members for the use of health services that result in unnecessary costs to PrimeWest Health or in reimbursements for services that are not medically necessary.

Sanctions against Members

PrimeWest Health may impose any of the following sanctions:

  1. Referring the member to the appropriate authority for possible criminal or civil legal action
  2. Recovery from the member, to the extent permitted by law, all amounts incorrectly paid by PrimeWest Health
  3. Restricted status: Requiring that the member receive health care from a designated primary care physician and other designated health service providers for a period of 24 months

A member may be given an additional 36 months of restricted status if patterns of program abuse continue and are supported by documentation. The PrimeWest Health RRP team conducts an end review to determine if the following occurred while the member was restricted:

  • Obtained services from a physician other than their assigned primary care provider without a referral
  • Obtained emergency room services for non-emergency care
  • Obtained prescriptions from a pharmacy that was not their assigned pharmacy
  • Obtained services from a provider they were not supposed to get services from

Notification and Member Rights to Appeal

PrimeWest Health must notify members in writing of any sanctions to be imposed. A member may Appeal any sanction proposed by PrimeWest Health.

Managed Care Organization (MCO) Restriction Status

PrimeWest Health and DHS have developed universal restriction, which is put in place by either PrimeWest Health or DHS and stays in effect for the entire period of restriction, regardless of whether the member:

  1. Changes health plans;
  2. Moves from fee-for-service to PrimeWest Health; or
  3. Moves from PrimeWest Health to fee-for-service.

When PrimeWest Health restricts a member, PrimeWest Health must enter the following information into MMIS:

  1. Name and PrimeWest Health ID number of the restricted member;
  2. Name(s) and PrimeWest Health ID number(s) of the provider(s) to whom the member is restricted;
  3. The date span of the restriction; and
  4. The reason codes for the restriction.

Denial, Termination, or Reduction (DTR) of Benefits Notice

For members enrolled in PrimeWest Health, any change in Service Authorization (Medical Service Authorization Request Form) or denial of a claim from a non-designated provider requires a DTR notice to the member. Placement in MRRP is not grounds for a DTR.

Obtaining Restriction Information

Providers may obtain information about the types of services to which a member is restricted by verifying eligibility (by phone at 1-866-431-0802 [toll free], through the provider web portal, or through MN–ITS). Typically, a member is restricted to one primary care physician, clinic, pharmacy, and hospital. A member may also be restricted to other designated providers or referred by the primary care physician to other providers, if appropriate. Members may receive services that are not subject to restriction from any enrolled PrimeWest Health provider. Long-term care facility (LTCF) services are not subject to restriction.

Selection of Providers by MRRP

A member placed on restriction is required to select a primary care physician, hospital, and a pharmacy to coordinate his/her care. If the member fails to choose providers, PrimeWest Health will assign providers based on considerations of geographic proximity, the member’s prior experience with a specific physician, and the physician’s willingness to provide health care services.

Members may be restricted to physician assistants (PAs) and nurse practitioners (NPs). PrimeWest Health can restrict the member to an NP if the NP has privileges at the member’s assigned hospital.

Responsibilities of the Primary Care Physician

Any physician enrolled as a general practitioner, internal medicine, or family practice physician may be selected by the member as his/her primary physician. The primary care physician will be asked to review each member’s profile of utilization, develop an appropriate care plan, and authorize referrals.

Limitations on Physician Participation

The commissioner may limit a primary care physician’s participation in MRRP based on the quality or quantity of health care services delivered or a review of sanctions previously imposed by PrimeWest Health or by the physician’s professional licensing board. The commissioner also may limit the number of members restricted to an individual primary care physician.

Personal Care Assistance (PCA)

The member may not use the personal care assistance (PCA) choice option or consumer-directed services. They may use the PCA shared care option if a county public health nurse (PHN) says it is appropriate.

Medical Referral for the Minnesota Restricted Recipient Program (MRRP)

The primary care physician must complete a PrimeWest Health Restricted Recipient Program (RRP) Referral Form on the PrimeWest Health web portal as soon as a member is referred to another physician for care. This information is necessary for the referring provider’s claim(s) to be processed in a timely manner.

Emergency Services

Emergency health care services may be provided to a PrimeWest Health member without the authorization of the primary care physician if these services are provided in response to a condition that, if not immediately diagnosed and treated, could cause a person serious physical or mental disability, continuation of severe pain, or death. PrimeWest Health may require documentation of the emergency situation in order to determine payment of the claim.

Program Requirements

In addition to MRRP, the provider(s) must follow all PrimeWest Health requirements (such as authorization, second surgical opinion, program limitations, etc.).

Claims Reimbursement

Services provided to a PrimeWest Health member will be reimbursed when:

  1. The service is provided by the member’s primary care physician or his/her designee;
  2. The primary care physician has submitted a PrimeWest Health Restricted Recipient Program (RRP) Referral Form as soon as a member is referred to another physician for care; or
  3. The service is of a provider or service type that is not listed as restricted on the member’s file.

Reporting Suspected Misuse of Services or Requests for Additional Information

To report actual or suspected fraud, abuse, or misutilization of service by a PrimeWest Health member, or for questions regarding PrimeWest Health’s Restricted Recipient Program (RRP), call 1-866-431-0802 (toll free).

For other questions regarding MRRP, call 1-651-431-2648 or 1-800-657-3674 (toll free).

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Updated_09/13/2022