PHYSICAL MEDICINE BENEFITS MANAGEMENT

Transcription

1 PHYSICAL MEDICINE BENEFITS MANAGEMENT

2 AGENDA

3 UTILIZATION MANAGEMENT PROGRAM

4 NEW REQUIREMENTS PHYSICAL MEDICINE SERVICES 4

5 CARE REGISTRATION For Initial 8 Visits the Member Utilizes Each Year 5

6 HIGHMARK NAVINET SCREEN 6

7 CARE AUTHORIZATION If Member Exceeds 8 Visits Each Year 7

8 RAPID RESPONSE SYSTEM

9 RAPID RESPONSE SYSTEM (RRS) 9

10 RRS CARE AUTHORIZATION 10

11 11

12 RRS CARE AUTHORIZATION 12

13 AUTHORIZATION PROCESS ~ LEVEL I 13

14 BAR CODE TECHNOLOGY 14

15 LEVEL II ~ PEER CLINICAL REVIEW 15

16 PROVIDER RECONSIDERATIONS AND APPEALS

17 17 RECONSIDERATIONS AND APPEALS

18 APPENDIX

19 PROVIDER RELATIONS - CUSTOMER SERVICE 19

20 UTILIZATION MANAGEMENT PROGRAM SUMMARY 20

21 21 APPLICATION OF CLINICAL CRITERIA

22 22 MEDICAL RECORDS SUBMITTED

23 MEASURING PATIENT RESPONSE ~ 23 o o o

24 PATIENT-SPECIFIC FUNCTIONAL SCALE 24

25 MEASURING PATIENT RESPONSE ~ *Fiese and Menke, Spine, Vol.26, no 1, pp , Jan

26 FUNCTIONAL RATING INDEX (FRI) 26

27 27 ASSESSMENT OF PATIENT RESPONSE

28 ADDITIONAL TOOLS FOR PROVIDERS 28

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31 HEALTHWAYS

32 Healthways Today Three Aims Help healthy people stay healthy Address health-related risks from lifestyle behaviors Optimize care for those with health conditions Broad Capabilities In health & well-being improvement Global Footprint 40 million+ participants 4 continents Solutions & Innovation Flexible solutions focused on quality, best science, and member experience Mission To create a healthier world one person at a time Experienced 30 years experience in chronic condition management and well-being improvement 20 years experience in physical medicine benefit management 32

33 Physical Medicine Benefit Management Services Commitment to the member experience; quality and service excellence Delivering complete insurance support capabilities since Network Development - Credentialing (NCQA certified CVO) - Utilization Management (URAC accredited since 1997) - Claims Processing Flexible solution design and delivery Proprietary Utilization Management Technology - Multi-level process utilizing the Rapid Response System Automated prescreening and treatment authorization Peer Clinical Review Multidisciplinary Clinical Support National Accredited Provider Networks 33

34 Clinical Leadership Kevin Basile, PT, MS, OCS Director, Clinical Services, PT/OT APTA advanced certified orthopedic specialist and advanced certification in manual therapy with15 years clinical experience including 8 years as a physical therapy peer reviewer; lectured nationally on various topics pertaining to physical rehabilitation and treatment interventions Member of 2008 & 2010 APTA task force to review and revise the APTA Guidelines William Dorney, DC, CHCQM Director, Clinical Operations & UM Certified in Peer Review & Health Care Quality Management with 30 years experience in Clinical Services, Managed Care Operations, UM Accreditation, Quality, and Compliance Former President and CEO of Alignis, Inc., a chiropractic & physical therapy MCO Roger Nelson, PhD, PT., FAPTA - Director, Expert Clinical Benchmarks Professor of Physical Therapy and internationally recognized educator and expert in the field of physical medicine; 52 peer reviewed publications and more than 100 professional presentations and two published books (one in the 3rd edition) in the area of Electrotherapy Represented the Physical Therapy profession on the Agency for Health Care Policy and Research (AHCPR) Low Back Guideline Panel; Chair of the National Institute for Occupational Safety and Health's (NIOSH) Low Back Atlas Study 34

35 Clinical Leadership (continued) Mark H. Nolting, ND, L.Ac, Dipl.Ac., Medical Director, CAM Services Board Certified, National Certification Commission Acupuncture & OM; former chair and faculty of acupuncture and Oriental medicine at Bastyr University 25 years clinical experience as naturopathic physician and acupuncturist; 12 years experience as CAM IME examiner Richard Olson, DC Director, Clinical Services 25 years as consultant in the Chiropractic profession and insurance industry including former National Chiropractic Consultant for The Travelers Insurance Company Author of Procedural Utilization Facts, Chiropractic Care Standards along with Chiropractic Care Plans, Best Practice Guidelines Andy Perez, MD Director, Medical Integrity & Science Functions as research clinical advisor and supports domestic and international Business Development and Strategic Development initiatives Former Associate Medical Director for Medical Policy Development for Blue Cross Blue Shield of Michigan, where he served as liaison for several professional societies 35

36 Clinical Leadership (continued) James E. Pope, MD Vice President and Chief Science Officer Oversees medical and scientific integrity, analytic consultative services, process quality improvements, outcomes and applied research Extensive publication history and recognized expertise in evaluating well-being interventions that control cost and improve quality of care Former President of HeartCare Institute of Tampa, former President and Medical Director of Florida Cardiac Network, Inc. 36