health partners/landmark healthcare provider seminar · pdf fileconfidential and proprietary...

Confidential and Proprietary to Landmark Healthcare, Inc. 1

Health Partners/Landmark HealthcareProvider SeminarJune 10, 2013

Introduction

Health Partners has partnered with Landmark Healthcare to utilize their expertise in the management of outpatient therapy


Agenda

• Landmark Overview

• Medical Necessity

• UM Program Overview

• Landmark Connect™• Treatment Plan Forms

Helene Graham

Director, Therapy Services

• Date Extensions, Retrospective Requests, and Appeals

• Claims

• Provider Tools

• Contact Information

Vycki Rupakus

Clinical Manager, Case Management


Landmark Overview

• Manage physical medicine services for insurance companies and employer groups since 1985– To reduce unnecessary

utilization– Encourage efficient and effective

care

• 7 million lives under management

• Provide clinical management through – treatment plan review– authorization of visits– and provider education

• Office locations– Corporate headquarters in

Sacramento, CA– Clinical services offices in PA, MI

and HI– Colorado Springs, Colorado– Bluffton, South Carolina


Accreditation

Landmark follows the most stringent rules.•URAC – Landmark awarded full accreditation for Health Utilization Management since 2005.

– URAC is an independent organization that reviews. operational policies and procedures.

– Assures safeguards for consumers, providers and employers.•Licensed as a Certified Review Entity by the Pennsylvania Department of Health since 2006.•Adheres to the strictest published standards.

– Department of Public Welfare (DPW).– Pennsylvania Department of Health.


Landmark’s Therapy Team

Therapists’ Experience•Average 25+ years in clinical practice•Leadership positions with state PT associations•Adjunct faculty in PT academic programs, clinical instructors

Medical Directors’ Experience•Average 18+ years in clinical practice•Physician specialties: Physical rehabilitative, occupational and internal medicine, pediatrics

Rehabilitation Advisory Panel•Providers from different clients and states•Policy and CPG review •Varied background to give a broad perspective


Our Clinical Philosophy

• Patient‐centered care founded on best available evidence

• Functionally oriented and measurable treatment programs

• Focus on skilled therapy interventions

• Empower patient independence


Our Management Principles

• Clinical Practice Guidelines are transparent and dynamic

• Condition‐specific treatment plans require the minimum information necessary to make an educated decision

• Quick turn‐around time to avoid delays in care

• Certain practice variation cannot be explained or justified

• Landmark staff are available to assist you– Clinical case managers are available throughout business hours

to answer clinical questions

– Customer Service agents have extended work hours to meet your needs


Program Goals

• Review treatment plans and authorize visits

• Educate providers to improve practice patterns

• Promote evidence‐based practice

• Provide Clinical Practice Guidelines to support authorization decisions and educate providers

• Decrease or eliminate unexplained practice variation and unnecessary visits

• Keep costs under control so members can continue to receive quality care, skilled services


Confidential and proprietary to Landmark Healthcare, Inc. 10

Medical Necessity

Medical Necessity Definition

DPW (Department of Public Welfare): A service or benefit is medically necessary if it is compensable under the MA program and if it meets any one of the following standards:

•The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition, or disability;

•The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury, or disability;

•The service or benefit will assist the member to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the member and those functional capacities that are appropriate for members of the same age.


Medical Necessity DefinitionDOH: Department of Public Health•Services or supplies that a provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease or its symptoms, and that are:

•In accordance with 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, physician, or other healthcare provider, 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.


Medical Necessity

How do we determine “clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient’s illness, injury, or disease”? •The services shall be considered under accepted standards of medical practice to be a specific and effective treatment for the patient’s condition.

•The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist. Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional.


Medical Necessity

Clinical appropriateness continued:•There must be an expectation that the patient’s condition will improve significantly in a reasonable (and generally predictable) period of time, or the services must be necessary for the establishment of a safe and effective maintenance program required in connection with a specific disease state. In the case of a progressive degenerative disease, service may be intermittently necessary todetermine the need for assistive equipment and/or establish a program to maximize function

•The amount, frequency, and duration of the services must be reasonable under accepted standards of practice and supported by evidence.


Medical Necessity

For these purposes, “accepted standards of medical practice”means standards that are based on credible scientific evidence published in the peer‐reviewed literature generally recognized by the relevant healthcare community, specialty society evidence‐based guidelines or recommendation, or expert clinical consensus in the relevant clinical areas.


APTA Code of Ethics:

Principle #3: Physical therapists shall be accountable for making sound professional judgments. (Core Values: Excellence, Integrity)•3A. Physical therapists shall demonstrate independent and objective professional judgment in the patient’s/client’s best interest in all practice settings.

•3B. Physical therapists shall demonstrate professional judgment informed by professional standards, evidence (including current literature and established best practice), practitioner experience, and patient/client values.

•3C. Physical therapists shall make judgments within their scope of practice and level of expertise and shall communicate with, collaborate with, or refer to peers or other health care professionals when necessary.

•3D. Physical therapists shall not engage in conflicts of interest that interfere with professional judgment.


Review for Medically Necessary Care

Clinical Case Managers review for:•The need for skilled services by the therapist

– Level of complexity requires the skills of a therapist

– The frequency of care needed

•Initiation of a home program to transition exercises from the clinic to the home environment as soon as the member can perform the exercise.Transition strengthening and stretching, which take repetition to be effective, to the home management program.

•Whether the patient can be taught to do this independently or with the help from a caregiver.

•The progress (or lack of progress) of the patient

•Patient compliance


Health Partners Benefit Covers…

Medically necessary visits only

• Medical necessity is determined by ongoing assessment of the patient

•Not “what the doctor ordered” but what the patient needs to return to basic function

The provider is responsible for communicating with the referringphysician regarding the plan of care and patient progress



Program Overview

Program Overview

Oversight of Physical, Occupational, and Speech Therapy utilization.

•Condition specific treatment plan forms for PT, OT, and ST

•Communication of determination decision remains unchanged

– Letters will be sent to the provider, the PCP, the ordering physician (if different from the PCP) and the member

– Letters will be faxed to the provider; in the event the FAX fails, a call will be placed to the treating provider advising them of the review decision

– The member will be notified of each review determination based on regulatory requirements


8‐Visit Waiver• Treatment Plan submission after an 8‐visit waiver

– 8 visit waiver renews yearly in January

– Combined 8 visit waiver for PT and OT

– Separate 8 visit waiver for ST

• If unsure whether the waiver has been used, contact HP or submit a Treatment Plan to request authorization. The Provider Helpline number is 215‐991‐4350.

• Once you submit a treatment plan, continue submitting a treatment plan.


8‐Visit Waiver

• Due to mid‐year implementation, effective July 1, 2013, the

8‐visit waiver will be available for all new patients

– Combined 8‐visit waiver for PT and OT

– Separate 8‐visit waiver for ST

• All prior HP authorizations will be honored

• For patients under active care, the 8‐visit waiver visits available will be decremented from services rendered on or after July 1st

regardless if the service has been authorized. Any remaining visits available from the 8‐visit waiver may then be used before requesting additional authorization.


Waiver Scenarios1. A patient who has not had any therapy visits in the calendar year sees

you for Physical Therapy treatment. You may render up to 8 visits before you request authorization.

2. A patient sees you for Physical Therapy and also is scheduled to receive Occupational Therapy. The patient may receive the 8‐visit waiver for PT and OT but those 8 visits need to be split. Both disciplines should have separate treatment plans and goals.

3. A patient who has not had any therapy visits with any provider in the calendar year sees you for Physical Therapy Treatment. You submit a treatment plan requesting authorization of visits after the first visit. Once a treatment plan is submitted, you must continue to submit treatment plans until the next calendar year when the waiver refreshes.


Waiver Scenarios4. A patient who has received both PT and OT during the calendar

year now receives a referral for Speech Therapy. The patient has not had any Speech Therapy visits in the calendar year. The patient may receive up to 8 visits before requesting authorization for additional visits.

5. A patient is continuing care and receives an authorization from HP for 7 visits from June 15 to July 15, 2013. If the patient needs to continue care after July 15, any remaining visits from the 8 visit waivermay then be used before requesting additional authorization.

Ask the patient or contact HP to confirm that no other provider has rendered care to the member before assuming they have all 8 visits under the MEMBER centric waiver available.



Landmark Connect

Landmark Connect

Access Landmark Connect at www.LMhealthcare.com• Treatment plan forms and instructions

• Retrieval of determination letters

• Date Extension forms

• Access to resources

• CPGs

• OA Toolbox

• UM Guide and FAQs

• ICD‐9 look up

• Documentation guidelines


Register for Landmark Connect!

• Access Landmark Connect at www.LMHealthcare.com• Click on

Landmark Connectfrom the Providers section



• Click “Register”

• Agree to the Terms and Conditions



• Download the Landmark Connect user application and fax your request to Landmark.

• For assistance, call Landmark at (877) 531‐9139


Landmark Connect


PatientSearch


e‐Forms


Resources



Treatment Plan Forms

PT/OT Treatment Plan Forms

Providers report pertinent information on condition‐specific forms•Standard Therapy Treatment Plan

•Hand Therapy Treatment Plan

•Lymphedema Management Treatment Plan

•Neurological Rehabilitation Treatment Plan (for pediatric and adult patients)

•Vestibular Rehabilitation Treatment Plan

•Supplemental Joint Form (to be submitted together with a Treatment Plan when additional joint measurements need to be recorded)


Speech Treatment Plan Forms

• Pediatric Speech and Language

• Neuro (Adult & Pediatric)

• Voice

• Supplemental Swallowing Form


General Rules

• All fields must be completed

• Writing must be legible

• “Start date for this treatment plan”: must be within 7 days from the date you submit your authorization request

• “Date of current objective findings”: must be current and not older than 7 days from the start date of care

• The functional scale must be completed

• Requests for additional visits during an existing Approved Time Period should only occur when there is an unexpected change in the patient’s condition


PT/OT Treatment Plan with Instructions


PT/OT Treatment Plan (bottom)


Speech Treatment Plan Form with Instructions


Common Errors

• Start date for this treatment plan

• Red flag field

• Laterality of joint

• Date of the PSFS findings

• Incomplete fields


Authorizations

Include two elements:

•Number of approved visits

•Approved Time Period (duration, typically 30 days)

Spread the approved visits across the entire Approved Time Period to avoid a gap in care


Overlapping Requests(Additional Care Within an Existing Approved Time Period)

Authorization of additional visits during an existing Approved Time Period will only be considered if there has been a significant change in the patient’s condition. If this occurs, the provider will be required to:

Submit an updated treatment planExplain why the visits were not spread over the entire duration of the authorization

Landmark will send a Request for Information letter if medical necessity cannot be established.


Overlapping Requests(Additional Care Within an Existing Approved Time Period)

Based on the requested Start Date, Landmark will do one of the following:

•If requesting additional visits 8 or more days BEFORE the expiration of an existing authorization

– Landmark will review and consider more treatment within this SAME existing authorization time period

•If requesting additional visits 0‐7 days BEFORE the expiration of an existing authorization

– Landmark will review and consider more treatment with a NEW authorization and time period (30 additional days).

Unless Landmark missed essential information, the provider will be asked to submit an updated treatment planConfidential and Proprietary to Landmark Healthcare, Inc. 44

Overlapping Request Example> 7 days overlap

8‐Visit Waiver Utilized

1st Treatment Plan submitted and approved

•6 Visits 8/1/2013‐8/31/2013

•Spread the 6 visits through the 30 day duration

2nd Treatment Plan submitted with a start date of 8/22/2013.

•No additional visits are medically necessary (during the current Approved Time Frame through 8/31/2013)

•New denial authorization for 8/22 – 8/31/2013

3rd Treatment Plan submitted with a start date of 9/1/2013

•6 visits 9/1/2013 – 9/30/2013


Overlapping Request Example> 7 days overlap with medical necessity


1st Treatment Plan submitted and approved•6 Visits 8/1/2013‐8/31/2013


2nd Treatment Plan submitted with a start date of 8/22/2013.•Additional visits are medically necessary (during the current Approved Time Frame through 8/31/2013)

•The patient fell and had a major setback…

•New authorization for 8/22 – 8/31/2013 for 2 visits

3rd Treatment Plan submitted with a start date of 9/1/2013•6 visits 9/1/2013 – 9/30/2013


Overlapping Request Example< 7 days overlap


1st Treatment Plan submitted and approved

•6 Visits 8/1/2013‐8/31/2013


2nd Treatment Plan submitted with a start date of 8/28/2013.

•No additional visits are medically necessary (during the current Approved Time Frame through 8/31/2013)

•Landmark will move the start date to 9/1/2013 (Approve other than as requested)

•4 visits 9/1/2013 – 9/30/2013

3rd Treatment Plan submitted with a start date of 10/1/2013

•2 visits 10/1/2013 – 10/30/2013Confidential and Proprietary to Landmark Healthcare, Inc. 47

Request for Additional Treatment Within an Existing Authorization Period



Date Extension Requests, Retrospective Reviews, and Appeals

Date Extension RequestsForms are available on Landmark Connect (www.LMhealthcare.com)ADULTS•Limited to ONE date extension per treatment plan; expiration date will be extended up to a maximum of 30‐Days

– NOTE: if the provider is requesting an extension LESS than 30 calendar days it will be approved as requested. This request will “exhaust” the one date extension allowed per Treatment Plan request

•If additional care is required beyond the first date extension, submit a new Treatment Plan with updated clinical information

•Landmark will deny additional date extension requests and request you submit a Treatment Plan with updated clinical findings

•The time limit for submitting a date extension request is within 30 days of the authorization end date.


Date Extension Requests

Pediatric Patients:•Limited to TWO date extensions for children (under age 21); expiration date will be extended for a maximum of 30‐Days for each request

•If additional care is required beyond the second date extension, submit a new Treatment Plan with updated clinical information

•Landmark will deny additional date extension requests and ask you to submit a Treatment Plan with updated clinical findings

•The time limit for submitting a date extension request is within 30 days of the authorization end date.


Date Extension


Retrospective ReviewsRetrospective authorization requests = all visits for a member

have already occurred. • Prior authorization is required (before you provide services).

• Retrospective reviews will be accepted ONLY if there is a compelling reason that is out of the provider’s control, such as a member retro‐eligibility.

• Provide a copy of all clinical documents (i.e., evaluations and progress summaries, Treatment Plan, daily progress notes, outcomes assessments, flow sheets) for the services provided.

• A Request For Information (RFI) letter will be sent if the information is incomplete.

• Insufficient or missing clinical information may result in a denial.


Retrospective Reviews


Appeals

• Landmark will be delegated for 1st level provider appeals (disputes regarding a denial based on medical necessity)

• Health Partners will continue to manage:– Claims appeals

– Member appeals

– Provider 2nd level appeal

– Member and provider complaints

• A provider appealing on a member’s behalf is considered a member appeal and is handled by Health Partners


Claims Submission

• Claims submission requirements remain the same with the following exception:– Providers should no longer submit PT/OT/Speech Therapy claims using date spans

– Providers should submit each service as a single date


Clinical Practice Guidelines

Outcome Assessment Toolbox

Other Resources

58Confidential and Proprietary to Landmark Healthcare, Inc.

Provider Tools

Tools ‐ Clinical Practice Guidelines

• Proprietary, highly developed, diagnosis specific focused on medical necessity and functional improvement.

• Not visit prescriptive.

• Developed from mainstream literature and journals.

• Includes input from practicing providers.

• Updated annually with multiple levels of review.

• Available on LandmarkConnectSM

Confidential and Proprietary to Landmark Healthcare, Inc.

Clinical Practice Guideline Development

Practitioner Advisory Committee

External Consensus Development

Systematic Reviews

PT/OTClinicalPractice

Guidelines

Clinical Management Team

Internal Consensus Development

Specialty Content Advisors

Specialty ExpertsProvider Association

Quality ImprovementSteering Committee

Published Guidelines

Peer- Reviewed Literature

Seminal TextbooksExisting Practice Guidelines

Landmark’s Historical Utilization Data

60Confidential and Proprietary to Landmark Healthcare, Inc.

On‐line Clinical Practice Guidelines


Outcome Assessment Toolbox

Provider Resources


Communication

Contact Information

• Office hours:– Monday ‐ Friday – 8:30 a.m. to 8:00 p.m. Eastern Time

• Toll‐free number: 1‐877‐531‐9139• Fax number 1‐888‐565‐4225• Address:

Landmark Healthcare, Inc.1750 Howe Ave, Suite 300Sacramento, CA 95825



Questions and Answers

health partners/landmark healthcare provider seminar · pdf fileconfidential and proprietary...

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