GLMS UHC IIRC Thursday, March 24, 2016 GLMS/First Floor Boardroom 7:30AM

Transcription

1 GLMS UHC IIRC Thursday, March 24, 2016 GLMS/First Floor Boardroom 7:30AM Committee Members in Attendance in Bold Brian Sosnin, DO UHC IIRC Chair Julie Daftari, MD UHC KY Medical Director Billy McCord UnitedHealthcare Network Physician Management Molly Mills-Kidd UnitedHealthcare Provider Advocate Cathy Owens UHC Physician Network Contractor Tess Wheeler LCKMGMA Representative, All Women OB/GYN Stephanie Woods GLMS Senior Advocacy Specialist Natalie Mesbah GLMS Administrative Assistant, PEPS Department SUMMARY Action Steps :06 WELCOME AND INTRODUCTION The committee welcomed Kris Miracle, Billing Office Manager for Advanced ENT & Allergy. :16 Review December UHC IIRC Meeting Summary Dr. Sosnin requested the committee members review the December minutes from the last IIRC meeting. Stephanie Woods asked Tess Wheeler if she had any more questions concerning UHC s OB/GYN member benefit and copay policies. Tess responded that their questions have been answered and there is no longer an issue. Dr. Sosnin informed the committee that Stephanie s UHC formulary spreadsheet was organized well and the links were helpful. Dr. Sosnin made a motion to approve the December summary and the motion was granted. Summary approved, no changes or revisions 2:49 6:35 Old Business Stephanie Woods began this discussion by asking the UHC representatives about the requirements for genetic counseling. Stephanie recently read the requirements in the March bulletin and wondered if that information resolved the questions that arose during the initial discussion at the December meeting. Dr. Daftari stated she was not sure of Molly Mills-Kidd s progress on the questions but would follow up with her on those requirements and then inform the committee. Stephanie informed the committee that more information on the process was provided by Cathy Owens and it is located under the Addendum section on page six. UnitedHealthcare (UHC) Updates Network Bulletin Billy McCord distributed to the committee the most important updates from the January, February, and March Network Bulletins. Below are some of the items that were discussed from those bulletins. PAs Required for Select Musculoskeletal and Pain Management Procedures, Effective April 4, 2016 UHC will add select musculoskeletal and pain management procedures to their prior authorization list. These PAs will be required for procedures on the following list performed in all sites of care including inpatient/outpatient hospitals, ambulatory surgery centers and offices: Arthroplasty, Arthroscopy, Foot Surgery, Spine Surgery, and Back Pain Implants. Radiology Program Procedure Code Changes, Effective January 1, 2016 UHC updated the procedure code list for the Radiology Notification and Prior Authorization Programs based on code changes made by the American Medical Dr. Daftari to check into requirements for genetic counseling & follow up with the committee. 1

2 12:50 Association. Claims with dates of service on or after 01/01/16 are subject to these changes. The full list of procedure codes requiring Notification or Prior Authorization in 2016 is available on UnitedHealthcareOnline.com>>Clinician Resources>>Radiology>>Radiology Notification & Prior Authorization for Commercial Plans; Medicare Advantage Radiology Prior Authorization Program for Medicare Plans; or UnitedHealthcare Community Plan Radiology Prior Authorization Program for Medicaid plans. UnitedHealth Premium Designation Program, Reconsideration Process Enhancements When a provider submits a reconsideration request, they may include the detailed patient and episode information they feel is necessary to explain the reason for the request. Additional documentation may also be submitted to support the request for a correction or change. Once the review has been completed, the provider will be able to view the full, detailed status of the Reconsideration Results Report by logging on to UnitedHealthcareOnline.com>>Quick Links>>UnitedHealth Premium>>Premium Reconsideration>>Reconsideration Status. The Premium program will continue to accept reconsideration requests until July 15, Due to enhancements made, data refreshment will not happen until Change to Supply Policy, Bundling Code L8680 with Code for UnitedHealthcare Commercial and Medicare Advantage Members To further align with the Centers for Medicare and Medicaid Services, UHC will enhance the Supply Policy to deny HCPCS code L8680, Implantable neurostimulator electrode, when billed with CPT code 63650, Percutaneous implantation of neurostimulator electrode array, epidural, in an office or non-facility place of service. This is effective for UHC Commercial and Medicare Advantage members for claims with dates of service on or after May 1, IMRT Stimulation Update Effective for claims with dates of service on or after April 4, 2016, UHC Medicare Advantage will not reimburse for CPT codes 77280, 77285, and for radiation therapy for a member during the development of the intensity-modulated radiation therapy (IMRT) plan (on the same or different dates of service). PAs for Functional Endoscopic Sinus Surgery Beginning May 2, 2016, some functional endoscopic sinus surgery procedures will be added to UHC s prior authorization list for many UHC commercial plans and UHC Community Plans (Medicaid), excluding Medicare Dual Special Needs Plans and Medicare Medicaid Plans. Medical necessity reviews will be required for all UHC Community Plan and commercial members for these procedures in all states. For some members, the medical necessity review will include a review for the appropriate site of services when the procedure is requested to be performed in an outpatient hospital setting. Stephanie introduced Kris Miracle of Advanced ENT to the committee. Kris attended this meeting to discuss the dilemma that this new requirement will cause when one of her physicians needs to perform an emergency procedure on a patient who is critical need. Kris asked the UHC representatives present what happened to cause this new policy. Dr. Daftari responded that the PA requirement is to ensure that the procedure is medically necessary and not 2

3 causing additional complications that need to be addressed from performing the procedure. Kris gave a realistic scenario of how a PA on nasal/sinus endoscopy, surgical; with control of nasal hemorrhage (CPT code 31238) would negatively affect a patient who was bleeding profusely from the nose. If the physician who was in charge of controlling that bleeding had to wait for approval on a prior authorization request before he could perform cauterization, the patient s health would be in jeopardy. Dr. Daftari informed Kris that with all of the prior authorization requirements, there is always a pathway for emergency situations. UHC encourages physicians to address the patient s needs in emergency situations and then submit the PA request after. However, if the medical records indicated the procedure was not an emergency or medically necessary, the PA request would be denied after the fact. Kris asked Dr. Daftari if UHC allows a certain time frame after the surgery for the PA request to be submitted. As an example, if one of their physicians were called into the Emergency Room, on a weekend, to stop nasal hemorrhaging. Could the PA be submitted when the office opened on Monday? Dr. Daftari responded that there is a timeframe but she will have to verify what it is according to the guidelines and then follow up with Kris. She also informed the committee that the guidelines can also be found on UnitedHealthcareOnline.com. Stephanie Woods researched the timeframe during the discussion and found that the initial PA needed to be submitted within 48 hours of the procedure. Dr. Daftari to verify time requirement to submit PA for CPT & follow up with Kris Miracle. Tess Wheeler asked Dr. Daftari if a PA for CPT could be submitted beforehand, in the event it is needed. Dr. Daftari responded that UHC requests at least two weeks to approve a PA request for an elective procedure so that a clinical review for medical necessity can be performed. Once the PA has been submitted, the practice will receive a notification number and then they will receive a follow up authorization number once the request has gone through clinical review. However, PAs based on a health situation that might happen, but might not, would most probably be denied. Kris asked Dr. Daftari if it was their practice s responsibility to submit and obtain a PA if the surgery was performed in an ER. Dr. Daftari confirmed that it is the physician who is billing for the surgery s responsibility to submit and obtain the PA. If the surgery is performed in an Emergency Room during a time when the physician s office is not open, the office can submit a retro-authorization request the next business day. She did inform the committee that the timeframe could be supported by an explanation and considered on a case-by-case basis. The committee continued to discuss the various scenarios of how physicians balance procedures and informing the correct person of those procedures, especially in emergency situations outside of their office. Dr. Sosnin invited Kris to inform the committee should problems arise after the policy implementation. New Helicobacter Pylori Serology Testing Medical Policy UHC introduced a new medical policy, effective January 1, 2016 for UHC Commercial health plan members 3

4 regarding H. pylori serology testing. The guidelines state that serology testing (CPT code 86677), which does not test for an active H. pylori infection, should no longer be used. The guidelines state that stool antigen test or urea breath test should be used rather than serology testing to both diagnose and confirm eradication of an active H. pylori infection. The medical policy reflects a test, treat, retest, and confirm eradication policy in cases of H. pylori infection. UHC developed the H. pylori testing policy from guidelines issued by the American Gastroenterological Association and the American College of Gastroenterology. Non-Participating Lab Practices, Waiving or Capping Member Cost Share Prohibited Some nonparticipating labs attempt to attract customers by waiving or capping copayments, coinsurance or deductibles. Such arrangements undermine the benefit plan by eliminating incentives created to encourage members to choose to receive care within the network and to discourage overutilization of services. UHC benefit contracts exclude coverage for any out-of-network lab services for which the provider waives the coinsurance, copayments or deductibles. IN addition, routine waiver of coinsurance, copayments or deductibles may be a violation of the Federal False Claims Act, subject to investigation by the Office of the Inspector General and/or any applicable state insurance department s fraud division. Removal of PCP Name on Individual Exchange ID Cards The primary care provider s (PCP) name has been replaced with PCP Required on the front of the member identification cards for Individual Exchange members in UnitedHealthcare Navigate, Compass and Charter benefit plans. The purpose of this change is to alert the physician s office that a PCP is required for this type of benefit plan and that one has been selected by the member or assigned by UHC. New Intensity-Modulated Radiation Therapy Policy Effective for claims with dates of service on or after June 1, 2016, UHC will implement the Intensity-Modulated Radiation Therapy policy to further align with the Centers for Medicare & Medicaid Services. If simulation services have been previously paid and a subsequent claim is received for payment of the IMRT plan, UHC will retroactively adjust prior payment for the simulation services. This new policy will apply to services reported using the 1500 Health Insurance Claim Form or its electronic equivalent or its successor form. 49:15 New Business Dr. Sosnin asked the UHC representatives if there are any trends in medicine and patient care that they would like to share with the committee. Dr. Daftari responded that there is still a big push for value-based contracting and how UHC can be creative with incentives that would encourage practices/providers to administer the quality of care UHC expects. Also, it is HEDIS season and UHC is interested in addressing any questions or concerns from practices/providers who are unsure of what information needs to be provided and in what amount of time. Dr. Sosnin asked Dr. Daftari what type of trends are appearing for Patient Centered Medical Homes (PCMH) and pay-for-performance incentives. Dr. Daftari responded that Indiana has a large amount of PCMHs and they hold a large enough amount of members to enter into those type of agreements. However, within Kentucky, UHC has to work on finding enough members to 4

5 enter into those types of agreements. UHC has to invest a large amount of resources into PCMH agreements so the benefits have to be weighed before approaching those groups. The threshold must be at 5,000 attributed members. Dr. Daftari projected in 2017 and in 2018 meeting that requirement within Kentucky. The resources UHC invests into a PCMH arrangement include twice monthly meetings with a dedicated Practice Performance Manager and Dr. Daftari, a Clinical Practice Consultant, strategies for improvement in quality, communication of UHC data, clinical action plans, and implementing strategies that positively affect other MCO relationships within that ACO. Billy McCord contributed that UHC is going to be adding more Provider Advocates to their team so that physicians will be able to have an increased relationship with a person who can navigate their needs through UHC s network. 48:20 The next meeting will be Thursday, June 30, 2016, at 7:30am in the 1 st floor Board Room at GLMS. Stephanie Woods also motioned to confirm UHC IIRC meetings for the rest of the year (09/29/16 and 12/15/16). This motion was approved by Dr. Sosnin and others in attendance. All committee members confirmed the date and were sent calendar invitations. 1:05:29 Adjourn Addendum: Dr. Julie Daftari provided a link on Tuesday, March 29 th to UHC s BRCA resources, fulfilling an action item. b10a Dr. Daftari informed the committee in an dated Thursday, March 31 st that nasal/sinus endoscopy, surgical; with control of nasal hemorrhage (31238) with a site of service billed as ED will not be subject to PA. Natalie Mesbah forwarded the to Kris Miracle of Advanced ENT & Allergy. 5