1 eviCore Imaging Management and Enhanced Musculoskeletal Review - - PowerPoint PPT Presentation

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eviCore Imaging Management and Enhanced Musculoskeletal Review

OEBB

April 4, 2017

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• Today Moda partners with AIM to prior authorize Advanced Imaging

services.

• Effective April 1, Moda began utilizing eviCore Health to provide prior

authorization services.

History

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Beginning April 1st, Moda Health is engaging eviCore Health to perform prior

• authorization. eviCore is available to perform prior authorization for the following

services:

Moda and eviCore partnership

Advanced Imaging (AI) Radiology Cardiology Ultrasound – OB & Non‐OB Musculoskeletal (MSK) Spine & Joint Surgery Interventional Pain Physical Therapy, Occupational Therapy, Speech Therapy Alternative Care – Chiropractic and Acupuncture

Ultrasounds are not currently subject to prior authorization for OEBB. This will take effect 10/01/2017.

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− In times of rapidly rising health care costs, Moda Health strives to offer groups and members quality at an affordable price point. Performing prior authorization review, which focuses health care dollars on services that meet evidence based criteria, is one approach to maintaining affordable premiums. − Impact on OEBB’s premiums

• By approving Moda to move forward with an enhanced care

management program allowing for a more rigorous approach to advanced imaging and musculoskeletal services focused on prior authorization, OEBB reduced its premiums by 0.85%. This equates to approximately $5 million annually.

Why is Prior Authorization Important?

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• eviCore offers expertise in a broader array of services than

Moda’s previous vendor

• Familiarity with the Oregon market

− eviCore is currently provides the set of PA services offered to Moda customers to other health plans in Oregon. − Providers are familiar with their systems and processes, thus minimizing member and provider impact

• Prior Authorizations for Alternative Care and Therapies are new to

Moda but they are not new to the Oregon market − eviCore has met with the OIC and Oregon professional societies as it has implemented programs with other health plans.

• NCQA/URAC Accredited
• eviCore’s criteria is aligned with professional societies

governing the services it specializes in.

Why eviCore?

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• Moda’s implementation of the eviCore programs is unique to Moda and is highly

customized based on the needs of our members. Many decisions have been made that are specific to Moda

The Moda/eviCore Relationship

Service Level Guarantees

• Call response time
• Medical necessity determination turnaround times
• System availability
• No financial incentive to deny care
• Call response time
• Medical necessity determination turnaround times
• System availability
• No financial incentive to deny care

Claims Processing

• Moda will continue to process claims internally
• Moda will continue to process claims internally

Programs

• Customized number of visits approved during ‘registration/notification’
• Therapies reviewed/approved at visit level, not unit level
• Customized number of visits approved during ‘registration/notification’
• Therapies reviewed/approved at visit level, not unit level

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• eviCore will be held accountable financially to service levels for

the following metrics:

• Average Speed of Answer (30 seconds or less)
• Abandonment Rate (3% or less)
• Standard Med Nec TAT (3 business days)
• Urgent Med Nec TAT (lesser of 2 business days or 72 hours))
• System Availability (available 7am to 7 pm PST 99% of the time) Fax

and Web requests are available 24/7 − Moda will review regular reporting of these metrics and holding both formal and informal meetings with eviCore Account Service

• Management. Financial penalties apply when service levels are not

met.

The Moda/eviCore Relationship

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Provider communication

• Initial Outreach – January 2017

− Top 25 impacted contracted providers were personally notified with feedback requested − Letter sent to impacted contracted providers notifying them of the upcoming change. It included information related to checking Benefit Tracker (EBT) for member impact based on their employer.

• Detailed Communication ‐ February – March 2017

− Meeting held with key Therapy providers (2/6/17)

• Multiple follow up conversations are being held to discuss value based

contracting and options for delegation of prior authorization. − Meeting held with acupuncturists and lobbyist (3/20/17)

• Communicated Moda’s unique relationship with eviCore
• Listened to their concerns/suggestions. Will evaluate suggested

modifications to processes. − Follow up letter from eviCore to all providers of impacted services (mailed 2/20/2017) − Service‐specific training webinars held March 6 – April 6th. − Personalized on‐site training has been offered to key providers of services. − Third letter, including implementation detail, mailed 3/27.

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OEBB Member communication

• Communication sent in March based on utilization within the last

12 months for the following services:

− Advanced Imaging Therapies (physical therapy, occupational therapy, speech therapy) − Acupuncture − Chiropractic

• Letters mailed to all members who used a out‐of‐network

providers

• Email notification sent to all subscribers with valid email on file

who used in‐network and/or out‐of‐network providers

• Letters mailed to all members who used in‐network providers and

did not have a valid email address on file with Moda

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Appendix

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Services grid

The grid below summarizes prior authorization services today compared to a scenario where eviCore is engaged to provide services. Note: Ultrasound section does not apply to OEBB members until 10/1/2017.

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Services grid continued

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• eviCore is aligned with professional societies of the specialties it offers

programs in: − American Academy of Neurology − American College of Rheumatology − American Association of Neurological Surgeons − American Academy of Orthopedic Surgeons − American Society of Interventional Pain Physicians − American Pain Society − Medicare Guidelines − American Physical Therapy Association − American Chiropractic Association − American Speech Language Hearing Association

eviCore alignment with Professional Societies

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Radiology & Cardiology Solutions

Managing care for 65M (Rad) & 46M (Card) Members Commercial, Medicaid, and Medicare Flexible pricing model Local and national programs

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Self‐referrals Inappropriate imaging costs the system $3B & $1B annually

http://www.radiologybusiness.com/topics/healthcare‐economics/rsna‐2016‐reasons‐wasteful‐imaging‐%E2%80%94and‐how‐fix‐them

Medical legal concerns – defensive imaging Provider unfamiliarity with clinical evidence Communication barriers

Drivers of Inappropriate Imaging

Inappropriate Imaging & How to Fix It eviCore’s cost & quality medical benefits management solutions ensure that patients receive the right care at the right time

Repeat imaging

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Chest CT scans yield incidental findings 19%

• f the time

Incidental Findings Study

Nearly 10% of brain MRIs result in incidental findings MRIs of the lumbar spine have an 8.4% incidental findings rate Lumbar‐spine CT scans have a 40.5% rate of incidental findings Between 40% and 70%

• f CT scans of the

abdomen turn up incidental findings

http://www.wsj.com/articles/when‐a‐medical‐test‐leads‐to‐another‐and‐another‐1472494983 Sources: Radiology; Canadian Association of Radiologists Journal; American Journal of Roentgenology; Dr. Stella Kang, NYU Langone Medical Center

Unnecessary MRIs and CT scans lead to unnecessary surgeries, radiation, tests, and procedures 10%

Our Radiology solution improves patient safety through the reduction of unnecessary and harmful downstream procedures

8% 40‐ 70% 41% 19% 63%

CT colonography scans, to screen for colon cancer, have a 63% incidental findings rate

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Radiology Solution Covered Services

• Advanced imaging services
• CT, CTA
• MRI, MRA
• PET, PET/CT
• Nuclear Medicine
• Primary imaging services
• OB Ultrasound
• Non‐OB Ultrasound

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Cardiology Solution Covered Services

• Advanced imaging and diagnostic services
• Stress Testing
• Myocardial Perfusion Imaging (SPECT &

PET)

• Stress Echocardiography
• Cardiac CT & MRI
• Echocardiography; Transthoracic,

Transesophageal

• Diagnostic Heart Catheterization
• Implantable Device Services
• Pacemakers
• Implantable Cardioverter‐Defibrillator

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Musculoskeletal Solution

Managing care for 34M members Commercial, Medicaid, and Medicare Flexible pricing & payment integrity National & local programs

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Musculoskeletal by the Numbers

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Musculoskeletal physicians on staff

66

Musculoskeletal‐trained nurses on staff

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Million lives covered

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Musculoskeletal therapists

(PT/OT/ST/MT/CHIRO/ACU)

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• Spine Surgery
• Fusions
• Decompressions
• Disc replacements
• Large Joint Surgery
• Joint replacement
• Arthroscopy
• Open procedures
• Interventional Pain
• Spinal injections
• Spinal denervations
• Stimulators/pain pumps
• Specialized Therapy Management
• Physical / Occupational / Speech Therapy
• Chiropractic / Acupuncture / Massage
• Implant Management
• Claims Review
• Utilization Management

Musculoskeletal Solution Covered Services

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Hip Replacement Spinal Fusion

Joint replacements and spine fusions are on the rise

MSK Market: Surgery Growth Trends

Growth in key procedures for MSK Care1

2002‐2011

1 HCUP Nationwide Inpatient Sample (NIS)

Knee Replacement

88%

increase

308k to 714k

67%

increase

34%

increase

276k to 462k 344k to 460k

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MSK Market: Total Joint Replacement Trends

More replacements, younger patients,

increasing trends

TKA surgeries unnecessary2

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1 HCUP Nationwide Inpatient Sample (NIS) 2 http://onlinelibrary.wiley.com/doi/10.1002/art.38685/full

73% 123% 54% 120% 188% 89% 0% 50% 100% 150% 200% Overall 45‐64 65‐84

2000‐20091

Increase Age Group

Total Hip Arthroplasty (THA) Total Knee Arthroplasty (TKA)

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