L.A. Care Health Plan Medical Management Quarterly Technical Bulletin 1Q10 - March 2010

Transcription

1 Medical Management Quarterly Technical Bulletin 1Q10 - March 2010 Editor In-Chief: Z. Joseph Wanski, MD, F.A.C.E. Contributing Editor: L.A. Care Health Plan Lynnette Hutcherson, RN Medical Director, Medical Management Director, Medical Management (213) ext.4388 (213) ext 4427 jwanski@lacare.org lhutcherson@lacare.org IN THIS ISSUE Changes in Requirements for Physician Review of Denials Medi-Cal Criteria for the Surgical Treatment of Morbid Obesity L.A. Care s Hospitalist Program L.A. Care s Delegated Concurrent Review Pilot Project Is Your Referral Request Really Urgent? L.A. Care s Program of Predictive Modeling (MRx) as an Effective Medical Management Tool Changes in Requirements for Physician Review of Denials I am pleased to inform you that DHCS has changed contractual language previously requiring physician review of all denials (benefit and medical necessity) now to only those denials for medical necessity. Surgical Treatment of Morbid Obesity Use of Evidence-Based Criteria-by Milliman, Interqual, and Apollo- is well established by our Participating Physician Groups (PPGs), but when Medi-Cal Fee for Service or Medi-Cal Managed Care have separate criteria for a particular procedure, Medi-Cal criteria takes precedence over all other criteria. Surgical treatment for morbid obesity 1 is one of these, and is provided here for your use: Medi-Cal Criteria for Morbid Obesity: Surgical Treatment Surgical treatment of clinically severe obesity (Body Mass Index [BMI] of greater than or equal to 40) should not be billed with CPT-4 code (unlisted procedure, stomach), but should be billed with specific CPT-4 codes. Morbid obesity can be a health danger because of the associated increased prevalence of cardiovascular risk factors such as hypertension, hypertriglyceridemia, 1

2 hyperinsulinemia, diabetes mellitus and low levels of high-density lipoprotein (HDL) cholesterol. Conservative and dietary treatments include low ( ) calorie and very low ( ) calorie diets, behavioral modification, exercise and pharmacologic agents. When these less drastic measures have failed or are not appropriate, providers may use the following surgical treatment options for morbidly obese recipients. Prior authorization is required. CPT-4 Code Description Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) with gastric bypass and small intestine reconstruction to limit absorption placement of adjustable gastric band (gastric band and subcutaneous port components) revision of adjustable gastric band removal of adjustable gastric band removal and replacement of adjustable gastric band removal of adjustable gastric band and subcutaneous port components Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty other than vertical-banded gastroplasty Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy ( cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Rouxen-Y gastroenterostomy with small intestine reconstruction to limit absorption Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric band Gastric restrictive procedure, open; revision of subcutaneous port 2

3 43887 removal of subcutaneous port Removal and replacement of subcutaneous port Referral Requirements Approval of a Referral or Treatment Authorization Request (TAR) for CPT-4 codes 43644, 43645, , 43842, 43843, and is required and must include all of the following documentation: The recipient has a BMI, the ratio of weight (in kilograms) to the square of height (in meters), of: Greater than 40, or Greater than 35 if substantial co-morbidity exists, such as life-threatening cardiovascular or pulmonary disease, sleep apnea, uncontrolled diabetes mellitus, or severe neurological or musculoskeletal problems likely to be alleviated by the surgery. The recipient has failed to sustain weight loss on conservative regimens. Examples of appropriate documentation of failure of conservative regimens include but are not limited to: Severe obesity has persisted for at least five years despite a structured physician-supervised weight-loss program with or without an exercise program for a minimum of six months. Serial-charted documentation that a two-year managed weightloss program including dietary control has been ineffective in achieving a medically significant weight loss. The recipient has a clear and realistic understanding of available alternatives and how his or her life will be changed after surgery, including the possibility of morbidity and even mortality, and a credible commitment to make the life changes necessary to maintain the body size and health achieved. The recipient has received a pre-operative medical consultation and is an acceptable surgical candidate. The recipient has an absence of contraindications to the surgery, including a major life-threatening disease not susceptible to alleviation by the surgery, alcohol or substance abuse problem in the last six months, severe psychiatric impairment and a demonstrated lack of compliance and motivation. The recipient has a treatment plan, which includes: Pre-and post-operative dietary evaluations and nutritional counseling, counseling regarding exercise, psychological 3

4 issues, and the availability of supportive resources when needed Repeat bariatric surgery or surgical revision may be medically necessary to correct complications or technical failure including implanted device failure, gastric pouch of inappropriate size or stricture, fistula, obstruction or other surgical complication. Request for repeat surgery for failure to achieve or sustain weight loss must include documentation that the patient has been enrolled in and compliant with the previous post-operative program. Authorization for bariatric surgery will only be approved for a Center for Medicare & Medicaid Services certified Center of Excellence (as designated by the American Society for Bariatric Surgery or certified Level I Bariatric Surgery Center by the American College of Surgeons). 1 Medi-Cal.ca.gov_ publication surgery digestive system _ L.A. Care s Hospitalist Program In an effort to better manage the care and services provided to members admitted to a hospital, improve care coordination and potentially decrease inappropriate hospital utilization, the L.A. Care Medical Management Department has implemented a new program utilizing the PPG s hospitalist programs. The goal is to ensure that contracted physicians whose primary focus is inpatient care (hospitalists) at high-volume hospitals will provide inclusive health care and management to L.A. Care patients in the hospital. L.A. Care staff collaborated with the contracted PPGs to develop two key resources to assist in the program. One, a list of all of the PPGs with hospitalist programs and two, a list of L.A. Care contracted hospitals covered by a PPG hospitalist. The resources identified that 99% of L.A. Care s membership is covered by a PPG with a hospitalist program. Education and training were provided to both LA Care and PPG staff on the use of the resources and expectations that all in-network admissions would be evaluated to ensure that, when appropriate, a PPG hospitalist would manage the care of the patient. The exclusions to the program have been admissions to county facilities, one-day stays, neo-natal care, maternity, CCS cases, and out-of-area cases. When cases are managed by a L. A. Care UM Nurse, at the time of the initial admission review, UM nurses verify whether the attending physician is a PPG hospitalist. If not, where appropriate, staff work with the hospital staff, the attending physician and the PPG to transition the member s care to the PPG s hospitalist. Patients admitted to out of network hospitals are monitored to facilitate their transfer, when stable, to an innetwork hospital as expeditiously as possible. 4

5 Additionally, L.A. Care recently identified hospitals that have admitted ten (10) or more patients from a single PPG, where there are no hospitalists. We are validating the information with the PPGs and assisting with identifying physicians who could be utilized by the PPG to provide hospitalist services at these or other hospitals. In an effort to assist in controlling inappropriate admissions through emergency rooms, L.A. Care will be updating the PPG hospitalist information on a quarterly basis which will then be distributed to the emergency departments of our contracted hospitals. This is to assure a PPG s hospitalist is identified and involved as early as possible in the admission. L.A. Care has also begun discussions with a few PPGs and hospitals on potentially having patients evaluated by the contracted hospitalist in the emergency rooms. 11 M L.A. Care s Delegated Concurrent Review Pilot Project L.A. Care is exploring delegation of inpatient and concurrent review services to high performing PPGs. For the direct lines of business, L.A. Care has several contracted risk arrangements to manage the health care delivery system. Traditionally, while the risk arrangements are often shared, L.A. Care has retained financial and clinical responsibility for the management of acute and sub-acute admissions. While this has been one standard by which contracts are managed, it is not without issues. PPGs often have care managers responsible for coordinating the care of members both inpatient and outpatient. Hospital staff are often confused on who is responsible for making the approval decisions for continued care, who receives the clinical reviews and who arranges the discharge planning needs. Due to membership growth of 30%, a pilot was proposed to enable PPGs experienced in managing hospital care to assume delegation of this responsibility. Medical Management staff developed a series of metrics used to assess PPGs readiness for delegation. These reports included review of the annual audit results, self-reported utilization metrics (bed-days, discharges and length of stay), and clinical oversight with staffing and reporting capabilities. In September 2009, UM began the pilot with the two PPGs, Preferred IPA and AltaMed Health Systems. Phase 2 is expected to roll out in May If your PPG is interested in participating in the program, you may contact Lynnette Hutcherson, RN Director of Medical Management at (213) ext Is Your Referral Request Really Urgent? L.A. Care has received many routine referrals that are inappropriately marked as urgent. These are identified as duplicate requests submitted on the same day as one marked routine on the first submission and urgent on the second duplicate submission. The negative overall outcome is that L.A. Care responses to PPG referral requests are 5

6 slowed down, members and providers are dissatisfied with the referral processing and there are redundant workflows that cause staff dissatisfaction. PPG staff were queried to better understand why the duplicate submissions and urgent request for services that are not meeting the urgent care criteria. Staff responded that they found it is helpful to mark it urgent or put in multiple requests so they get a faster response from the health plan. Medical Management staff would like to provide you with a few tips on submitting appropriate health plan referrals: Urgent referrals are usually services related to services whereby a physician has determined that the care to be provided cannot wait for the routine five business day processing Referrals are submitted using L.A. Care contracted providers Submit all of the pertinent medical codes for accurate processing and medical records to substantiate the urgency of the request An L.A. Care nurse or physician will review every Urgent request to determine if the request meets criteria for urgent. If the referral meets criteria for urgent processing, it will be processed in the urgent timeframe of 72 hours from the date of receipt. However, If the physician determines that the request does not meet criteria for urgent, the physician will change the status to routine and then the referral is processed within the five (5) business day timeframe for routine referrals. Please help by submitting referrals as Urgent only when the referral is actually urgent. And please do not submit more than one request for the same referral. If you have submitted a referral and do not have a response within the timeframe or the member s condition changes, please call L.A. Care s Medical Management Department toll free authorization line (877) to verify the status of the referral. Please also refer this information to your PCPs and Specialists. L.A. Care s Program of Predictive Modeling (MRx) as an Effective Medical Management Tool L.A. Care s direct line of business membership surpassed 100,000 covered lives in December 2009 of which L.A. Care s Direct Line Medi-Cal Membership (MCLA) represents 60%. L.A. Care has adopted predictive modeling as a tool to proactively identify medically complex and ill MCLA members who might benefit from case management. The goal is to proactively identify these individuals and have them case managed before they require hospital and emergency room services. Medical Management teamed with the L.A. Care Health Outcomes and Analysis staff to explore the application of two predictive modeling tools, MRx and CDPS. Both are validated predictive modeling tools, developed at University of California, San Diego, based on the Medicaid population and utilize age, sex, diagnostic, and pharmacy data 2. Chronic Illness and Disability Payment System (CDPS) is designed to predict cost 6

7 based on the principle that an individual s risk score tends to increase with each additional condition that the individual has. MRx uses pharmacy data to predict potential future risks of incurring costs for each Medi-Cal member. Each tool assigns a risk score to reflect potential future cost. For example, a risk score of 1.5 predicts an expenditure that is 50% higher than someone having score of 1.0. MRx can potentially identify high risk members as soon as there is one month of medication profile and demographic information. Member s identified as potential high risk are evaluated further for possible care management interventions. Staff are also exploring the possibilities of utilizing CDPS in the early identification of children potentially eligible for CCS services. If you would like more information on L.A. Care s predictive modeling program, please contact Lynnette Hutcherson, RN. 2 Issue Brief_Selection of Medicaid Beneficiaries for Chronic Care Management Program: Overview and Uses of Predictive Modeling; April