Benton Giap, MD MBA

Overview of Utilization Management

222

Anthem Company Background

•Anthem is one of the nation's leading health benefits companies.

▪ With nearly 69 million people served by its affiliated companies including more than 37 million enrolled in its family of health plans

▪ One in nine Americans receives coverage for their medical care through Anthem's affiliated plans.

•Lines of Business

▪ Commercial

▪ Government (Medicare and Medicaid)

▪ Specialty Business Division (Dental, Disability and Life )

333

444

Objectives

▪ Common reasons why medical requests/claims are denied

▪ Communication -Do’s And Don’ts

▪ Process of Utilization Review and Appeal

555

Example #1

•68 yo female suffered a left internal capsule ischemic CVA 2 days prior. Uncomplicated post stroke recovery. Records show PMH of controlled hypertension, hyperlipidemia and DM. CVA work up- CT, biochemical profile, ECHO-unremarkable.

•Patient is currently on the stroke unit. Hospitalist requests for comprehensive inpatient rehabilitation.

•How would you handle this request ?

666

How would the health plan handle the request?

• a. approve request since patient has a qualifying diagnosis

• b. inpatient rehab admission does not need pre-authorization

• c. ignore the request since it is not from a rehabilitation physician

• d. request for peer to peer discussion to discuss request since there is inadequate information

777

888

CORRECT ANSWER

•request for peer to peer discussion to discuss request since there is inadequate information

Additional Clinical Information

• Patient is medically stable• Recent therapy

evaluations– ADLs – Supervision level– No obvious cognitive

deficits– No dysphagia– Mobility

• Transfer CGA• Gait 80 feet with AD with

supervision

101010

Peer to Peer Interaction

▪ Who is on the other end?

• Physicians • UM and CM RNs• Therapy Staff • Supporting/

Administrative Staff

111111

Communication Tips Do’s and Don’ts

• Remember that information transfer is incomplete - #1 reason for denial

• What has been attempted to get the information before doctor to doctor peer discussion

• Timeliness in responding to PTP requests• Remember your staff represent you

- Physician Extenders - Generally we do not do PTP with medical students or

first year house staff

121212

Documentation Challenges

•Provide us with the needed information▪ Know your patient and relevant information

• collaterals (i.e. therapists evaluation)

• “robo-documentation” from EMR

•Document more effectively▪ Clear and concise reasons /justification for level of care

•

131313

Communication Tips

•‘ The medical reasons for this level of care are..”

•“The active medical issues that require my daily management are..”

•

“ The medical complications/setbacks have been”. We are asking for an extension for these reasons/or to accomplish these treatment objectives…

•“The barriers to a safe community discharge are…”

141414

Example #2

•21 year old male involved in a MVC 7 days ago with newly acquired spinal cord injury T4 AIS A. Did not require any surgical intervention. Has S/S autonomic dysreflexia, neurogenic bowel, bladder, and anxiety. No respiratory concerns. Despite pain, fully participating with PT and OT on acute floor.

•Mbr is in his third year of college from southern California. Supportive family in CA. Mbr meets IRF criteria and has been accepted by a CARF-accredited SCI Rehab Program in Southern California.

•Request is for an out of state, out-of-network SCI program and air ambulance.

151515

161616

How would you handle this request?

a. approve for out of state SCI, deny the air ambulance transport

b. approve for out of state SCI and the air ambulance transport

c. deny both for out of state SCI and the air ambulance transport

d. conduct a peer to peer discussion about to understand the medical necessity

171717

ANSWER

•conduct a peer to peer discussion about to understand the medical necessity

181818

Common Reasons for Denials

•1. Non-covered charges

•2. Referral or preauthorization required

•3. Out-of-network provider

•4. Minor errors

•5. Wrong insurance company billed

191919

Denial Rationale

•Services are deemed not medically necessary

•Services are no longer appropriate in a specific health care setting or level of care

•Services are considered experimental or investigational for this condition

•The effectiveness of the medical treatment has not been proven

•You are not eligible for the benefit requested under your health plan

202020

HOW TO GET TO YES

•Understand CGs’ and MPs

▪ Advocacy versus medically necessary

▪ Medical reason versus psychosocial reason

▪ Custodial Vs. Skilled care

•Opportunity to highlight your expertise

▪ Effective Communication

▪ Collegiality

▪ Up to date with your literature

212121

Value-Based Models of Care

•-Value-based models of Care/Center of Excellence

▪ Does every IRF needs to be good at everything?

▪ Benchmarking and Transparency

▪ Registry of treatment outcomes

• -Managing complex populations in post acute journey

▪ Needs for seamless transition

▪ Needs for more options - non-traditional models of services

▪ Enhanced access

•

222222

Types of Appeals•INTERNAL APPEAL

▪ Deny pre-authorization

▪ Deny post-claim service

•EXTERNAL REVIEW▪ independent third-party expert

•EXPEDITED REVIEW ▪ Pt currently receiving or you were prescribed to receive treatment; and

▪ A delay in treatment could seriously jeopardize your life or overall health, affect your ability to regain maximum function, or subject you to severe and intolerable pain; or

▪ if the issue is related to an admission or continued inpatient stay and pt has not yet been discharged.

232323

Disputes

•Calling Customer Service

•Obtain a Notice of Denial

•Ask for an Internal Review

242424

Regulatory and Decision Making

• Regulation

▪ Utilization Review Accreditation Commission (URAC)

▪ Department of Managed Healthcare (DMHC)

▪ Department of Insurance (DOI)

• Decision Making

▪ Medical Policy Technology and Assessment Committee (MPTAC)

252525

Take-Aways

• Know your patient/Highlight your expertise

• Effective /Clear and concise communication

• Collegiality /Courteous

• Understand health plan’s clinical guidelines and medical policies/ understand the Summary Plan Description as well as the plan's Evidence of Coverage

• Follow procedures in order to get coverage and approval