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Maryland AAHAM November 2012

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Doc#: UHC1032a

2Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Agenda

• 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


Administrative Guide and Network Bulletin Newsletter

• Administrative Guide

• Policy and Procedure Guide: Updated annually on or before April 1st.

• 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


Improved Health Care ID Card


Cardiology Notification Resources

Updates to the web page will include Link to CareCore Website through e-ServicesUpdated Preauthorization listFAQ’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


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 ICD-10 transition


ICD10


Medical Necessity Principles

Clinical appropriateness

Clinical effectiveness

Cost effectiveness

Clinical evidence

• 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.

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.


Medical Necessity Objectives

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.

• 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.


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Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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


• 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

Components of our Model

Evidence-Based Medicine Clinical Appropriateness

Clinical EffectivenessCost Effectiveness

Inpatient Care Management Concurrent or retrospective reimbursement

decision for inpatient bed days

Prior AuthorizationPre-service benefit coverage decision

for a service, procedure or test

Future component slated for 2013

Radiology and Cardiology Prior Authorization


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.


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

UHC: 0615s_02201202


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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

UHC: 0615s_02201202


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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

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 PlanAssessment of barriers to accessing care Faster outreach post-discharge and timely follow-up with member’s

primary care physicianDecreased readmission rateQuick identification of case management needs including mental

health and substance abuse issues Assist member in navigating the health care system


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]

mailto:[email protected]


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 e-mail 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?

Excellent

Very Good

Good

Fair

Poor

• 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

• Ratings emphasize patient care and satisfaction, using national clinical and service quality measures, health outcomes and patient feedback about their health care experience

UHC: 0615s_02201202


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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– Staying healthy– Chronic condition management– Responsiveness and care– Complaints and members leaving the plan– Health plan operations and customer service

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.


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


Physician Collaboration: View360

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• 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

UHC: 0615s_02201202


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.




Questions and Answers

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Documents

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statutory initiatives

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