Introduction to UCare’s Medical Policy Program

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•Why We Need Medical Policies•What is Medical Policy?•Overall Strategy•What is Next?•Who to Contact

Medical Policy Team:Mike Lynch, MD

Ariam De Leon, MDEmily Barton

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Why Do We Need Medical Policies?

• Move from using external guidance only (CMS, DHS) to incorporate our own resources (Interqual, clinical practice guidelines and now medical policies) along with external guidance

• Meet Exchange (UCareChoices)and NCQA needs

• Support Triple Aim:

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What is Medical Policy?• UCare documents that provide assistance in making

coverage determinations regarding health services

▫ Generally accepted, evidence-based, cost-effective, universal to all products (although coverage may differ by plan) and intended to help our providers improve the health of our members

• A medical policy ≠ coverage decision

▫ Allows us to better define our position in relation to CMS/DHS coverage determinations and the Exchange.

• Medical policies do not fully address payment or coding issues

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Medical Policy

Medical Director Decision

Member Eligibility

InterQual

Clinical Practice

Guidelines

EOC, COC, Contract

Legislative Mandates

(DHS, CMS)

Medical Policy & Coverage Determination

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Coverage Determination

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Phase 1: Development and

Publication

Phase 2:Implementation

Phase 3:Post-

Implementation

• Clarification and integration with payment policy

• Integration into systems and processes

• Internal operational use of medical policies

• Continued publication

• Measure the utilization,

effectiveness and outcomes

• Maintenance of medical policies

• Collect feedback

• Medical policy topic identified

• Medical Policy topic prioritized

• Review of literature and

clinical evidence

• Medical policy drafted

• IMPC discussion/approv

al

• QIACC or P&T Council

discussion/final approval

•Initial publication11/15/2013

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P & TPharmacy and Therapeutics

Council

IMPCInterim

Medical Policy Committee

QIACCQuality

Improvement & Credentialing

Council

Implementation Workgroup

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Complexities of Development and Implementation

Medical Directors

Product

Payment Policy

Coding

Claims

Customer Services

Provider Relations & Contracting

PEC

Clinical Services

Pharmacy

Government Relations

Marketing

Health Care Economics

Information Systems

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Approved Policies:• MyUCare/Resources:/Medical Policy

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2013 Plan:

2014: Continued implementation, new policy development, and policy approval

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External Publication: Providers

External Medical Policy site▫ External policy formats do not include internal operation instructions

or cost and audience information that the internal versions include

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External Medical Policy Site

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External Publication: Members

What is Next After Publication?

▫ Integration with: Payment policy Benefit design Products Networks and Systems

▫ Measurement

▫ Outcomes

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Phase 1: Development/Publication

Phase 2: Implementation

Phase 3: Post-

ImplementationDevelopment and final approval of a medical policy

Integration, publication, systems, products, operationalize

Utilization, effectiveness, maintenance, feedback

Who to Contact with Questions?If you have questions about the medical policy program, specific

medical policies, or if you receive questions from members or providers about the content of a medical policy, please forward them to Emily Barton at ebarton@ucare.org for her to triage

and track.

If you have comments or suggestions for a Medical Policy topic that you would like to see available, please fill out the Topic Request

form and inter-office it to Emily Barton.

Topic Request Form Located on the Resources tab under Medical Policies

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