WHAT IS MEDICAL MANAGEMENT? WHAT IS THE PURPOSE OF MEDICAL MANAGEMENT?

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1 WHAT IS MEDICAL MANAGEMENT? How health plans make decisions to approve payment for medical treatment is a poorly understood part of the healthcare system. One part of the process, known as medical management, is often viewed as a mysterious black box in the insurance process. Our goal at Health Republic is to shine the light on the process so that our members and providers can better understand how decisions get made and therefore more easily navigate within the healthcare system. WHAT IS THE PURPOSE OF MEDICAL MANAGEMENT? All insurance companies, including Health Republic, review certain medical services that members receive before, during, or after care is delivered. This medical management process (also known as utilization review) helps ensure that the treatment you receive meets certain standards of medical practice. It s a popular belief that the sole reason for these reviews is about cost. That is part of the reason since out-of-pocket cost to you, and cost to the health plan, are important but it is also about quality, safety and clinical outcomes of the care. Many people have the impression that more (and more expensive) care equals better outcomes, but studies show that isn t necessarily the case. In fact, the opposite is often true. For example, surgical technology has improved but the rates of failed back surgery syndrome, a condition where the surgery may make the pain even worse, have not declined.

2 WHAT GETS REVIEWED? A request for service can be reviewed: Before the service is performed (pre-authorization) this is typically done for elective (non-emergency) tests or procedures While the service is being performed (concurrent review) this is usually done during the course of a treatment, such as a hospital stay After the service is performed (retrospective review) this can be for elective or emergency services that were performed WHO MAKES MEDICAL MANAGEMENT DECISIONS? Initially, a nurse reviews clinical records sent from your doctor (or the practitioner requesting the treatment) and compares those to the request. This is known as medical necessity review. In order to decide if something is medically necessary for a particular individual, the health plan staff reviews the information using evidence-based (we ll cover more about these in a minute). The majority of the requests are approved at the first review. When a requested service is not approved (not meeting clinical criteria), that final decision is made by a physician. A nurse can approve a treatment decision, but only a physician can deny a request for service. There are NEVER any financial incentives to our employees or reviewers if they determine services are not medically necessary. It is their job as professionals to make sure the care you receive is medically necessary, and and protocols have been developed to assist them in this process.

3 THE PREAUTHORIZATION PROCESS HEALTH REPUBLIC NURSE RECEIVES: - Request for test/treatment - Clinical information about your condition NURSE Reviews: - Test/Treatment request - Your clinical information - Evidence-based clinical guidelines Nurse Assessment: Request MEETS Nurse Assessment: ADDITIONAL CLINICAL INFORMATION is needed from your doctor CASE PENDED for information Nurse Assessment: Request DOES NOT MEET Request AUTHORIZED Nurse notifies all parties Physician Assessment: Request MEETS HEALTH REPUBLIC PHYSICIAN REVIEWS CASE Physician Assessment: Request DOES NOT MEET Physician DENIES authorization. Nurse notifies all parties MEMBER/PHYSICIAN CAN APPEAL

4 WHAT FACTORS INTO THE DECISION? Is the requested service being delivered consistent with established evidence-based for the condition? Making decisions based upon the latest and best evidence that is available is important. What we know about medical facts, treatment and how successful they are, changes as new technologies, practices and research emerge. (As you may know, years ago the idea that healthcare workers should wash their hands before touching a patient was scoffed at by leading clinicians.) To guide their decisions, our staff uses evidence-based that are researched, updated and published by nationally recognized authorities. These type of guidelines (also known as clinical criteria) incorporates outcomes research to evaluate the effectiveness and safety of various treatments for multiple conditions. So when we make a decision based on evidence-based medicine, you know it comes from a fact-based background. Some of the criteria we use are: Centers for Medicare & Medicaid Services (CMS) MCG Criteria Medicare Benefit Policy Manual But, these are only guidelines, not rules. We also consider your specific condition and clinical situation and how those compare with the guidelines. Your doctor can request to see the criteria used in making any decision about your case by contacting us via at What is the setting requested for the delivery of service (also known as the level of care )? We want you to receive the care you need in the appropriate place and at the appropriate time. The evidence-based clinical criteria are tools to help us determine the level of care that meets your condition and the treatment requested. Many procedures that previously were only done in a hospital are now routinely performed in an outpatient ( ambulatory ) setting. An example of this are knee surgeries, both repairs and replacements, which are now often performed in an ambulatory setting. An ambulatory setting is usually more cost-effective, and safer, than being in the hospital unless you have an underlying condition or risk factors that require that you be admitted to the hospital. Alternatives to the hospital also apply to medical conditions with options for treatment such as a 23-hour observation room. Not being in a hospital setting for any longer than necessary helps to reduce your risk of catching some of the contagious infections that hospitals can harbor.

5 WHAT IS TIMING OF THE AUTHORIZATION PROCESS? For prospective reviews, if we have all the information we need to authorize a request, we will provide a notice to you and your doctor, by telephone and in writing, within 3 business days after we receive the request. The infographic below shows the timeframes and responses in the event that we cannot approve a request on the first review. Health Republic Insurance of New York TIMELINE OF AUTHORIZATION PROCESS *BUSINESS DAYS (Monday - Friday) TIMELINE OF AUTHORIZATION PROCESS DAYS WE HAVE ALL INFORMATION WE NEED TO AUTHORIZE REQUEST 3 Within THREE BUSINESS DAYS after receiving the request, we will provide a notice to you and your doctor, by telephone and in writing. WE NEED ADDITIONAL INFORMATION 3 45 YOU Within THREE BUSINESS DAYS we will let you and your doctor know we need additional information. This is usually a request for more clinical information about your specific condition or clarification about what treatment has already been tried. AND YOUR DOCTOR HAVE FORTY-FIVE CALENDAR DAYS TO SUBMIT REQUESTED ADDITIONAL INFORMATION 3 Within THREE BUSINESS DAYS of when we receive the additional information we ll notify you and your doctor of the decision, by telephone and in writing. WE DID NOT RECEIVE NECESSARY INFORMATION WITHIN FORTY-FIVE CALENDAR DAYS 15 Within FIFTEEN CALENDAR DAYS we will make a final decision.

6 IF YOU DISAGREE WITH A DECISION. If you want to appeal a medical necessity decision, you (or your designee or your provider) have up to 180 calendar days to request an internal appeal either by phone or in writing. You can appeal out-of-network service denials or out-of-network referral denials. There are first and second level appeals, and the process is explained in more detail in the Utilization Management document on the Health Republic website. WHAT ELSE? When you need a procedure or to be admitted to a hospital, we can assist you to safely transition back home or to the next level of care, such as rehabilitation, and then to remain as healthy as possible. We can help you in a number of ways: Case Management: A Case Manager is a nurse or social worker who assists many of our members with complex or chronic care needs to navigate through the health care system. If you think you might benefit from having a Case Manager work with you and your healthcare providers, feel to complete and submit a referral and send it to us or call us at Home Health, Outpatient Therapies, Equipment or Supplies: Part of your transition in care may include getting therapy in your home or another setting, or you may need some equipment or supplies. Some of these items may require prior authorization as well. Check your Certificate of Coverage to review the covered benefits within your plan or you can contact us at Member Services at for assistance. Medications: For more information about prescription medications coverage and access, please visit our pharmacy page. Next Steps in Your Care: Make and keep a follow-up appointment with your doctor after any visit to the hospital. This is one of the key actions you can take to keep from having complications and having to be readmitted. Make sure you know when you are scheduled for follow-up and keep that appointment. But, if you should need to talk to a doctor when yours is not available (and it s not an emergency), you can contact our telemedicine service and consult with a board-certified emergency room physician through Stat Doctors, by phone or video, on a 24/7 basis. Click this site StatDoctors.com to learn more. Staying Healthy: We offer Health Educators of Wellness Coaches who can help you learn how to improve your health for a number of chronic conditions, including asthma, diabetes, heart disease, chronic obstructive pulmonary disease (COPD), and hypertension. To find about more about these services, visit our Staying Healthy webpage.

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