MMAC Participant Lock-In Unit Report

January 2019


Cost Avoidance:                                                     $789,633.05

Lock-In Summary:

Biennial cases reviewed:  37
Six-month case follow-up reviews:  43
New Lock-In cases opened:  63
Watch cases opened:  31
No Abuse cases:  35
PENDS cases open: 349

Approximate number of active cases:                1807

Definitions/Descriptions of Lock-In Terms:

Biennial Reviews –Participants are locked in for two years of eligibility. Each month, reviews are conducted for those reaching their two-year mark (two years from the initial lock-in date to a provider). 

Six Month Case Follow-up Reviews – Monitors participant progress with regard to compliance. 

New Lock-In Cases – An initial review of 12 months of data indicates a pattern consistent with abuse of services or drugs.  As a result, the participant is locked into a physician, pharmacy or both. 

Watch cases –An initial review of 12 months of data indicates a potential for abuse of services or drugs.  An education letter is sent.  A six month follow-up review may be done. 

No Abuse –An initial review of 12 months of data has determined there was no abuse. No further action is taken. 

PENDS – Participant cases are tracked to ensure lock-in occurs when and if necessary.  “PENDS” are cases which are reviewed daily for activity. 

Cost Avoidance – Dollar amounts denied due to participants being locked in to providers.