Date post: | 30-Dec-2015 |
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Judy DeanManaging Director
Tips in Addressing Carrier Medical Directors
What Causes Payers to Expand Coverage Policies?
Additional new data is available (internal and external)A code changeCustomer requests (employers, patients, etc)Provider requestsIncrease in overturned denials
Stakeholders, (providers, KOLs, patients, employers and Societies) can create noise in the network asking for change, therefore, as Physicians and Professional Society, you can drive change to payer coverage policies
How Can You Be Heard?
Contact the Decision Makers - Make Noise in the NetworkTalk to the Provider rep assigned to you by the payerWrite a letter to the payer medical director
Appeal your DenialsTake Denials to the highest level of appeal possibleAsk for a meeting or a conference call with the medical policy
decision makerEducate your patients on appealing denials
Denial Appeals ResourcesKaiser Family Foundation and Consumers Union
Sitehttp://www.kff.org/consumerguide/7350.cfm
Insurance CarriersAetna Appeals Guide
http://www.aetna.com/provider/data/PhysicianInternalAppealRefGuide.pdf
Anthem/WellPoint Appeals Guidehttp://www.anthem.com/provider/in/f3/s4/t1/pw_ad089352.p
df
Cigna Appeals Policyhttp://www.cigna.com/health/provider/medical/procedural/cl
aim_appeals/appeal_policies_procedures.html
How Can you Be Most Effective?How Can you Be Most Effective?
Be available to the payer for questions or phone calls. (they are not very flexible on scheduling meetings or calls)
Be clear and concise regarding your position Follow up – the payer has hundreds of policies to review. Establish a relationship with the medical director who can
impact the policy, if possible. Ask for a policy change and be specific on what your
state needs Be familiar with the policy—with its benefits and its
drawbacks.
Preparation
Read the payer’s coverage policy and note the areas where you disagree or feel it can be improved—all policies are different
Ask your provider rep for the name, address and phone number of the medical director
Understand the high points of the key clinical studiesFeel comfortable with the PowerPoint presentation
How to Get the MeetingObtain the medical director contact information
through your existing contact baseHospital administrationYour carrier provider repYour denial management efforts
Request the meeting either through a phone call or through a brief but well written letter
Be persistent—the payer medical director has a many policies to manage and fewer people now on staff to help
Offer your help in developing criteria on patient selection
Form a relationship with the medical director. Be available to help his group write a fair policy for their members
Once you get the meeting—Words are Important
What you say What they Hear
Needs longer term data Investigational
Studies are sufficient Coverage now
Specialty Society Support Technology is wide spread enough for physician group to agree
High risk patient Inclusion limitations – i.e. High BMI
What is Most Helpful in Communicating with Medical Directors
Guidance on which patients are appropriate Clear Statements Outcomes Statement on evidence Statement on validity of evidence How to limit risk Clarification of coding if confusion exists in the field
Stay on Message
Ask for a policy changeData is sufficient nowData is long termFollow NIH guidelines without BMI limitationsDo not limit to 2 step procedureOther payers now cover SG, including UHC
Key points for the letterKey points for the letter
State your credentials and expertise Be specific regarding your support and any State Society
Support Reference key data and studies Specifically ask for a policy change and for the payer to follow
NIH guidelines for sleeve gastrectomy. Set a time to follow up. “ I will contact you in 2 weeks….” Indicate the procedure is not investigational and is widely
accepted within the physician community State that studies and data are sufficient to support payer policy Point out parts of the policy that need to be change Tell them how it impacts your patients and your practice of
medicine
Conclusion Be persistent to be heard Follow up with information The Manager of the Medical policy area may be responsive to
you, or help you get the ear of the Medical Director Noise in the provider network can have great impact on payer
policy Key opinion leaders help the payer by having clear input
regarding technology Specialty Societies and the physician network must get
involved to change policy. There has to be a reason for policy to change: a coding
change, additional evidence, a new society statement, letters from the state specialty societies
Payers are updating policies now and you can impact those policies.