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1 POPULATION HEALTH identifying implementation tactics Analyzing Trends in Utilization Management: A Focus on Regulations August 5, 2015
2 This presentation has been provided for informational purposes only and is not intended and should not be construed to constitute legal advice. Please consult your attorneys in connection with any fact-specific situation under federal, state, and/or local laws that may impose additional obligations on you and your company. Cisco WebEx can be used to record webinars/briefings. By participating in this webinar/briefing, you agree that your communications may be monitored or recorded at any time during the webinar/briefing. Attorney Advertising
3 Upcoming Webinars! We hope you join us for our upcoming webinars. For additional details, to register or to watch the recordings of previous sessions, visit 3
4 Webinar Presenters Bob Atlas, MBA, Moderator Strategic Advisor & President EBG Advisors Cheri Lattimer, RN, BSN Executive Director Case Management Society of America Garry Carneal, JD, MA President & CEO, Schooner Strategies Senior Policy Advisor, Kennedy Forum 4
5 Presentation Overview This session will examine the evolution of utilization management (UM) programs over the past three decades, with a detailed overview of how this managed care function is regulated. The webinar will focus on: Part I: The Rise of Utilization Management Part II: 2015 UM Survey Findings Part III: Regulation Oversight & Complexity Part IV: The Future of UM Part V: RegQuest Overview Part VI: Wrap-Up 5
6 Part I: The Rise of Utilization Management 6
7 The Rise of Utilization Management 1980s: During the rise of managed care, some utilization review organizations earned a less than stellar reputation for denying care based upon subjective review criteria 1990s: The proliferation of state legislation and the rise of URAC as an independent accreditation agency promoted more equitable and evidencebased workflow processes when medical necessity decisions were being made by health plans or their subcontractors 2000s-present: UM programs are now a part of a larger, integrated care management system and platform. Medical necessity determinations often are made within a larger package of medical management services and interventions geared towards optimizing clinical and financial outcomes 7
8 Defining Key Terms Care Coordination Utilization Management (UM) Case Management Disease Management Population Health Management External/Independent Review 8
9 Medical Management Evolution Early 1900s: Case management 1973: Federal HMO Act adopted 1978: Michigan establishes independent medical review between health plans and patients 1988: Maryland becomes first state to adopt UM Law 1989: Utilization Review Accreditation Commission (URAC) founded 1993: NAIC adopts Model UM Law 1995: Workers Compensation UM Accreditation Standards 1999: Case Management Accreditation Standards 2000: External Review Accreditation Standards 2002: U.S. DOL Claims Regulations 2008: Mental Health Parity Law Adopted 2010: Affordable Care Act 2015: Active Parity Implementation 9
10 Part II: 2015 UM Survey Findings 10
11 Utilization Management Survey History UM Guide published by URAC in 1999, 2001, 2005 Online Resource Guide by RegQuest in Methodology Builds upon previous survey work UM buckets Legal research State review What is not covered 11
12 Medical Management Surveys Utilization Management External Review Grievance Procedure/Administrative State Mental Health Parity Laws Case Management 12
13 Medical Management State and Federal Regulatory Provisions Medical Management Functions State Law State Regulations Federal Law Federal Regulations Total Case Management Disease Management Utilization Management Care Coordination 2,273 5, , ,993 2, , URAC 2005 Westlaw search 12/04 Grand Total 13,640 13
14 UM Regulatory Oversight: Key Buckets Scope & Applicability Regulatory Contact Information Registration/Licensure Requirements Program Requirements Reviewer Qualifications Appeals Process Internal External 14
15 From UM to Integrated Population Health Rise of population health management Reliance on complex, condition management Move to integration Need for cost containment Enforce mental health parity More high touch UM interventions Focus on clinical and financial outcomes Lack of standardization outside of basic UM practices Role of regulation is limited 15
16 UM Scope & Applicability Of the 55 states and territories surveyed, 46 currently regulate UM functions Of those 46 jurisdictions, UM laws/regulations applied to the following types of insurance coverage HMOs: 43 Insurers: 43 UROs: 35 TPAs: 35 UM types specifically referenced Prospective: 14 Concurrent: 14 Retrospective: had at least one stated exemption where the UM laws/regulations do not apply 16
17 UM Organizational Licensure & Certification Requirements 34 out of the 55 jurisdictions have established licensure/certification requirements Renewal Period: Annually: 16 Bi-annually: 14 Tri-annually: 2 No Renewal Specified: 2 Total requiring fees: 28 out of the 34 Licensure fees: $100 - $500: 13 $501 - $999: 0 $ $1500: 12 $ $3500: 3 Reduced/waived fee for URAC accreditation: 4 17
18 UM Program Requirements Key Program Requirements (N=46 states or territories that regulate UM) Clinical Review: 44 Prohibition Against Financial Incentives: 29 Telephonic Coverage: 39 Quality Control Assurance: 33 Delegated Oversight: 28 UM Reviewer Requirement: 43 Medical Director: 20 Same State Licensure: 23 Offshore Reviews: 0 18
19 UM Review & Appeals Number of Internal UM Appeal Levels? No Provision 35 Number of States Timeframe for Initial Determination: 24 Hours 1 48 Hours 6 72 Hours 2 5 Days 1 7 Days 1 10 Days 3 15 Days 2 Not Addressed 39 Number of States 19
20 UM Review & Appeals (cont d) Timeframe for Standard Appeal 2 days 1 4 days 1 10 days 1 14 days 1 15 days 1 18 days 1 20 days 2 30 days days 1 45 days 2 Number of States Additional Appeal Provisions Notice of Appeal Rights Extension Options Final Notification Provision External Review Provision Number of states/ter. (n=55) Timeframe Expedited Appeal 1 day 5 2 days 11 3 days 18 4 days 2 7 days 1 Not Addressed 18 Number of States 60 days 10 Not Addressed 11 20
21 Sample UM Appeal Policy 21
22 Understanding the Appeals Process Internal Appeals UM Appeal Timing Expedited vs. Standard Type: Prospective, Concurrent, Retrospective Administrative/Grievance Procedure Appeal Parity Appeal External Appeals External Review Appeal Regulator Complaints Accreditation Audits Arbitration Hearing Judicial Hearing 22
23 Part III: Regulation Oversight & Complexity 23
24 Insurance Types Commercial Insurance Group coverage above 50 Small group coverage Individual/non-group coverage Self-funded Government plan TriCare Medicare Medicaid Dual eligible Taft Hartley 24
25 Regulator Types Federal U.S. Department of Labor (DOL) U.S. Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) DOD/TriCare Office or Personnel Management (OPM) State State health agencies State Medicaid agencies State plans Accreditation agencies State insurance departments Accreditation Agencies 25
26 Regulator Guidance Federal Statute (e.g., Congress) Federal Regulations (e.g., CMS, HHS) State Statutes State Regulations Agency Bulletins Attorney General Opinions Federal and State Court Decisions Official Office Interpretations Government As Purchaser (e.g., OPM) Government As Grant Funder (e.g., AHRQ) Government Research (e.g., NIH) Government Associations (e.g., NAIC, NGA, NCSL) 26
27 Health Plan Offerings: Governing Factors State/Regulations/ERISA fiduciary duties Plan documents Summary of plan benefits (SPD) document Insurance policy Plan manuals Payer policies Contract requirements Medical director application of clinical guidelines Health plan configuration/culture Geographic locations 27
28 Mental Health Parity Mental Health Parity and Addiction Equity Act Creating a level playing field between behavioral and med/surg Non-Quantitative Treatment Limitation (NQTL) testing and disclosure 28
29 Parity Resource Guide 29
30 Part IV: The Future of UM 30
31 Assessing the Future of UM High Cost High Risk Care Lower Cost Better Health The Triple Aim Specialty Pharmacy & High Cost Medications Better Care Mental Health Parity Shared Decision Making 31
32 Assessing the Future of UM Collaborative Practice Framework Better Health Patient & Caregiver Patient- Centered, Preference & Direction Lower Cost Better Care 32
33 Part V: RegQuest Overview 33
34 Overview Online regulatory compliance guide Survey information summarized in actionable buckets Peer reviewed by regulators Updated regularly Conveniently formatted in both PDF and HTML versions Topical updates/issue briefs Convenient summary tables of key provisions Annual subscription with easy login 34
35 Utilization Management Module 35
36 UM State Surveys Each survey covers: Scope and Applicability Regulatory Information Registration/Licensure Requirements Program Requirements Reviewer Qualifications Reviews and Appeals 36
37 Part VI: Wrap-Up
38 Concluding Observations & Questions Bob Atlas, MBA, Moderator Strategic Advisor & President EBG Advisors Cheri Lattimer, RN, BSN Executive Director Case Management Society of America Garry Carneal, JD, MA President & CEO, Schooner Strategies Senior Policy Advisor, Kennedy Forum 38
39 Upcoming Webinars! We hope you join us for our upcoming webinars. For additional details, to register, or to watch the recordings of previous sessions, visit 39
40 POPULATION HEALTH identifying implementation tactics THANK YOU
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