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Maryland AAHAM
November 2012
Doc#: UHC1032a
Agenda
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Network Bulletin Newsletter
Medicare Product Rebranding ID Cards
Medicare Advantage Cardiology Notification
ICD10 update
Medical Necessity
Quality Initiatives (HEDIS, Stars, ED
Diversion)
• View 360
• Service Team-Email Address
• Questions and Answers
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Administrative Guide and
Network Bulletin Newsletter
• Administrative Guide
• Policy and Procedure Guide: Updated annually on or before
April 1st.
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Network Bulletin Newsletter
Published every other month starting in January
Alerts to changes in Policies and Procedures
Sign up to receive via e-mail
– UnitedHealthcareOnline-emailnews.com
– Tools & Resources > News > Receive the
UnitedHealthcare Network Bulletin via e-mail
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Improved Health Care ID Card
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Cardiology Notification Resources
Updates to the web page will include
 Link to CareCore Website through e-Services
 Updated Preauthorization list
 FAQ’s, crosswalk table, comparison grid and fax
forms
Cardiology Notification Resources:
UnitedHealthcareOnline.com > Clinician Resources
> Cardiology > Cardiology Notification Program
FAQ’s are available on UHC table
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ICD-10 Effective 10/1/2014
• Why the delay?
• Industry transition to Version 5010 did not proceed as
effectively as expected
• Providers expressed concern that other statutory initiatives
are stretching their resources
• Surveys and polls indicated a lack of readiness for the ICD10 transition
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ICD10
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Medical Necessity Principles
Based upon a foundation of evidence-based medicine, Medical Necessity is the process
for determining benefit coverage and/or provider payment for services, tests, or
procedures which are medically appropriate and cost-effective for the individual member.
• Key Attributes:
– Evidence-based medicine
– Member-centric clinical review
– Cost-effective options
• Rigorous and consistent clinical management of:
– Clinical effectiveness - Treatment of illness, injury,
disease or symptom must be proven to be clinically
effective.
– Clinical appropriateness - Type, frequency, extent
and duration of services must be appropriate for
individuals.
– Cost effectiveness - Services must not be more
costly than alternative services that are at least as
likely to produce equivalent therapeutic and diagnostic
results.
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Clinical
appropriateness
Clinical
effectiveness
Cost
effectiveness
Clinical
evidence
Medical Necessity Objectives
• Medical Necessity will help drive optimal patient outcomes
– We know there are gaps in providing consistent, high-quality
care across the country. Applying Medical Necessity criteria
based on the best-available clinical science improves heath
care quality by raising performance and reducing variation in
medical practice.
• Medical Necessity will help make care more affordable
– Medical Necessity allows care to be delivered appropriately
and efficiently based on the best clinical practices developed by
the medical community, which results in more affordable care.
• Medical Necessity will help drive administrative simplification
– Deploying Medical Necessity establishes more consistent and
streamlined procedures for our care provider network.
Medical Necessity is a continued evolution of our medical management
model. Using a Medical Necessity standard will help enhance high-quality,
affordable care that is administratively consistent with the industry.
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Why Medical Necessity?
 Providers are asking for increased administrative simplification and upfront payment
determination
– Provide more transparency and consistency in the coverage determination process
– Align review procedures with other payers (review for medical necessity & provide prior
authorization)
 The marketplace is asking for increased health care effectiveness and affordability
– Employers insist that dollars spent on health care must have a more meaningful impact
on quality and health care costs
– Members are asking us to provide pre-service knowledge of coverage for appropriate
decision making
 Opportunity to incorporate best practices and promote consistency across our benefit
businesses
– The growth of UnitedHealthcare through the purchase of health plans such as Oxford,
PacifiCare and MAMSI provides a unique ability to identify and leverage best practices
– Moving our clinical models closer together creates an opportunity to incorporate best
practices from across our benefit businesses
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Confidential
Components of our Model
Evidence-Based Medicine
Clinical Appropriateness
Clinical Effectiveness
Cost Effectiveness
Prior Authorization
Inpatient Care Management
Pre-service benefit coverage decision
for a service, procedure or test
Concurrent or retrospective reimbursement
decision for inpatient bed days
• Requires migration to the 2011 COC or
SPD that supports medical necessity as
a requisite for benefit coverage
• Medical necessity determination
applied to a service
• Based on our facility contracts
• Bed days or levels of care determined to
be not medically necessary are facility
liability; member is held harmless
Radiology and Cardiology Prior Authorization
Future component slated for 2013
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Facility Impact
Hospitals & Other Inpatient Care Facilities (i.e. SNF, LTAC, Acute Rehab)
Participating hospitals and other inpatient facilities:
• Effective 11/15/2012, protocol for facilities to confirm authorization is on file prior to a service being
performed (for services on the Advance Notification List)
• Effective 11/15/2012, Admission Notification Protocol enforced at 24 hours* with 100% reimbursement
reduction (*following weekday admission, or by 5PM on the next business day following
weekend/federal holiday admissions)
• We have mailed all hospitals an amendment adding language allowing the use of medical necessity
criteria in concurrent and/or retrospective review. The amendment also provides hospitals with new
reconsideration/appeal rights that align with our model’s guiding principle to pay for medically
necessary care.
Participating hospitals that sign the Medical Necessity Amendment Effective 11/15/2012:
• Hospitals participating under this amendment may be subject to concurrent and retrospective reviews.
• Facilities that sign the amendment are able to submit reconsiderations/appeals for administrative
denials for failure to comply with notification protocols, or denials due to services being rendered when
authorization was not on file, on the basis of medical necessity. Upon reconsideration/appeal, if service
is determined to have been medically necessary, administrative denial will be overturned.
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Quality ER Diversion, HEDIS and STARS
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A Changing Health Care Landscape
• New regulations, political forces and patient
expectations are changing health care in America
• Health plans and physicians are being called on
to close gaps in care and improve overall quality
• And increasingly, the Centers for Medicare and
Medicaid Services (CMS) is moving to tie
reimbursement for Medicare services directly to
patient outcomes
• Together, we can help Medicare beneficiaries get
the most from their benefits --- meaning better
use of limited resources and more satisfied
patients for you and your practice
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UHC:
0615s_02201202
What Does Quality Look and Feel Like?
By improving performance in:
• Diabetes management
• Medication management after
a heart attack
• Controlling high blood
pressure
• Medication management
• Managing antidepressant
medication
• Testing to diagnose COPD
• Complaints and appeals
• Call center customer service
More Medicare beneficiaries are:
• Preventing complications
• Maintaining an appropriate
medication regimen
• Lowering their risk of stroke
and heart disease
• Maintaining an appropriate
drug regimen
• Protecting mental health and
well being
• Managing their condition
• Resolving issues faster
• Getting what they need, the
first time they call
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UHC:
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Quality is Measured in Many Ways
• National measurement programs
reflect different dimensions of plan
performance and health outcomes
• Emphasize physician collaboration
and patient engagement
• Industry quality programs include:
– HEDIS (Healthcare Effectiveness
Data and Information Set)
– CAHPS (Consumer Assessment of
Healthcare Providers and Systems)
– HOS (Health Outcomes Survey)
– NCQA Accreditation
– Medicare Star Ratings
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UHC:
0615s_02201202
ED Diversion Program
Electronic Record Submission
• UnitedHealthcare Community Health plan is implementing an
ER Diversion program and is seeking cooperation from its
hospital partners for real-time electronic data exchange
within 24 hours from an ER visit.
• Advantage of the ED Diversion program:
 Total electronic data transmission & better information exchange
between the facilities and Plan
 Assessment of barriers to accessing care
 Faster outreach post-discharge and timely follow-up with member’s
primary care physician
 Decreased readmission rate
 Quick identification of case management needs including mental
health and substance abuse issues
 Assist member in navigating the health care system
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ER Diversion File Transfer
– FTP (File Transfer Protocol) Push – UHC will establish a VPN (Virtual
Private Networks) connection between UHC server network & the hospital
server network. This connection would be used by the hospital to
automatically push/send the file to UHC once the file has been
generated. This is the preferred method of receiving the ED Diversion
files.
– File Naming Convention: UHCP_HSPI_XX_MMDDYYYY.txt
UHCP=United Healthcare Community & State; HSPI= hospitals initials; XX
= State of hospital MMDDYYYY= date the file is being submitted
– FTP - UHC will establish an FTP Web Portal that uses a unique user id and
password for each hospital. The hospital would access the FTP Web
Portal daily to post the ED visits file.
– Secure E-mail – (Interim Solution) With a secure e-mail application; the file
would be encrypted upon being sent to the UHC’s ED Diversion e-mail
address [email protected]
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Steps to Participate
– The ER needs to identify a Communication Lead. This person should be
able to facilitate communication and broker decision making with the
Hospital’s IT department and any other hospital departments that will need
to be involved.
– UHC Community Plan will notify UHC IT of the ER’s intent to participate
and provide contact information for ER Communication Lead.
– UHC IT will work with the ER and Hospital to establish the FTP and/or email process. The ER Diversion Program will be included during the testing
of the receipt of the file.
– UHC IT will notify UHC Community Plan, UHC ER Diversion Program, and
the ER Communication Lead when the process has been established and
validated.
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What are Medicare Star Ratings?
• CMS publishes Star Ratings
annually to help consumers
compare Medicare Advantage
and Prescription Drug plans
• Plans are scored and paid by
CMS based on their overall
Star Rating performance
Excellent
Very Good
Good
Fair
Poor
• Ratings emphasize patient care
and satisfaction, using national
clinical and service quality
measures, health outcomes
and patient feedback about
their health care experience
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UHC:
0615s_02201202
2012 Medicare Star Ratings:
53 Quality Measures
• Includes patient experience and their
perception of their health
• Part D (Drug Coverage) - 17 measures
– Customer service
– Complaints and members leaving the plan
– Member experience - getting information and
drugs
– Pricing and patient safety
• Part C (Medicare Advantage) - 36 measures
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–
–
–
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Staying healthy
Chronic condition management
Responsiveness and care
Complaints and members leaving the plan
Health plan operations and customer service
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UHC:
0615s_02201202
HEDIS
• Healthcare Effectiveness Data and
Information Set
• HEDIS® is the gold standard in health care
performance measurement, used by more
than 90 percent of the nation's health plans
and many leading employers and regulators
. HEDIS ® is a set of standardized
measures that specifies how organizations
collect, audit and report performance
information across the most pressing clinical
areas, as well as important dimensions of
customer satisfaction and patient
experience.
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HEDIS
• HEDIS ® makes it possible to compare the
performance of health plans and further
allow Health plans to use the HEDIS results
to focus their efforts for improvement.
• HEDIS ® measures address a broad range
of important health issues. Among some of
these issues are, but not limited to:
– Controlling High Blood Pressure
– Comprehensive Diabetes Care
– Breast Cancer Screening
– *Copyright 2009, NCQA
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Physician Collaboration: View360
• Provides online, instant
access to patient’s
history
• Helps identify who may
need recommended
screenings, treatments
or exams
• Is updated monthly,
providing timely and
actionable information
• Fits into your busy
routine and workflow
• Displays up to 3 years of
claims history, including
prescriptions and lab
work
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UHC:
0615s_02201202
View 360
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Mid-Atlantic Advocacy Team
[email protected] for facilities
[email protected] for physicians.
Please continue to contact your Network Management representative,
for questions related to contractual terms, renewals and/or
interpretation.
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Questions and Answers
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