4/29/2014. April 30, 2014

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1 April 30, 2014 Rachel Peura, RN Educated in PA; worked in a variety of settings in PA including: Acute care In and outpatient medical rehab Office settings Clinical trials House supervisor positions Employed for the last 11 years in MT at a commercial health insurance company 2 I am currently employed at BCBSMT. BCBSMT is a Division of Health Care Service Corporation (HCSC), a Mutual Legal Reserve Company, an independent licensee of the Blue Cross Blue Shield Association. The views and opinions expressed in this presentation may not be construed to be those of BCBSMT nor HCSC. 3 1

2 By the end of the presentation you will have an increased understanding of health insurance, levels of care provision and alternatives to inpatient admission in order to effectively manage resources for your patients in critical access hospitals. 4 Background on health insurance Roles and responsibilities of a utilization management (UM) nurse Levels of provision of clinical care Types of reviews done Your role in partnering with the insurance UM nurse 5 Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care and health system expenses, among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is available to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization such as a government agency, private business, or not-for-profit entity. (From Wikipedia, the free encyclopedia) 6 2

3 Insurance companies are mandated to have, submit and follow a Utilization Management (UM) Plan. An insurance company s UM Plan outlines the practices and procedures of managing utilization of their enrollees or members. In MT this is mandated by the MT State Commission of Securities and Insurance (CSI) previously MT Department of Insurance (DOI) 7 Within a MT insurance company s UM Plan are definitions of medically necessary as well as references to criteria used to evaluate level of care (loc). A UM Plan could be thought of as the checks and balance of premiums paid by individual members or employer groups and the processes in place to determine appropriateness of services rendered. Bear in mind that an insurance company offers a wide variety of products or plans that vary in premium costs and breadth of coverage. 8 Utilization management is the evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan. (From Wikipedia, the free encyclopedia) 9 3

4 Employ licensed RNs with experience in clinical settings whose job is to fulfill the duties set forth in the UM Plan 10 Based upon clinical information submitted, is the requested level of care medically necessary when comparing standard published criteria to the clinical picture submitted. 11 Cigna HealthCare Definition of Medical Necessity for Physicians Medically Necessary" or "Medical Necessity" shall mean health care services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: in accordance with the generally accepted standards of medical practice; clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease; and not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease. 12 4

5 For these purposes, "generally accepted standards of medical practice" means: standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community; Physician Specialty Society recommendations; the views of Physicians practicing in the relevant clinical area; and any other relevant factors. Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents. ( 13 IP OP OBS SNF LTAC Rehab 14 Milliman Care guidelines (MCG)- Our evidence-based guidelines help providers and payors drive effective care in their own work and through the conversations that connect them. We provide fast access to globally sourced, clinically validated best practices that support clinical decision-making. Seven of the eight largest US health plans and more than 1,200 hospitals use our evidence-based guidelines and software. (MCG website) McKesson's InterQual Criteria products support better patient outcomes through integrated, streamlined care management processes and appropriateness of care support. Today, more organizations - payers and providers, public and private - rely on InterQual than on any other evidence-based clinical decision support criteria. Wide adoption of InterQual fosters alignment between payers and providers and focuses all stakeholders on ensuring consistent, clinically appropriate care decisions. (Interqual Website) 15 5

6 Prospective Concurrent Retrospective (Retro) 16 Awareness of the importance of plan notification Plans can impose a financial penalty on their members or admitting provider for failure to notify insurance of an IP admit Understanding the MN and LOC requirement for an IP admission as opposed to an observation stay Understanding the criticality of documentation in the UM insurance review process 17 Approval Approval of less days than requested Request for additional information Denial of services as NMN and/or services could have been provided in a lower level of care 18 6

7 If a prospective review does not occur, the facility biller will submit the claim and records may be requested by the claims examiner in order for a UM nurse to perform a retro review. If prospective review done and request is fully or partially denied, the facility may have the right to appeal the denial Submission of additional information will be reviewed by a physician who was not involved with the original denial Timely response to record requests may avoid delay of payment 19 Why Does An Insurance Company Care About Managing Utilization? UM Review is a regulated provision of health insurers 2. Services provided in an IP setting in order to be approvable and payable must be: Medically necessary Often but not always, the least costly alternative Reflective of nationally recognized criteria provided in the right location for the right amount of time 21 7

8 3. Like most processes in our nursing profession, clear and complete documentation makes the process quicker 4. As soon as reasonable (but within 24 hours) alert the insurance company once your patient is admitted 5. Be prepared to supply the admitting history and physical (it does not have to be dictated), treatment plan, and initial medication records 22 Nurses working for insurance companies are nurses just like you. Our tools are different but necessary in our current health care delivery system Together you and nurses working on the other side can advocate for effective use of limited resources while ensuring quality outcomes for people needing inpatient hospital services