CMS announced that as of January 1, 2018, total knee arthroplasty (TKA) will be removed from the Medicare IPO for procedures reimbursed only under IPPS. Now hospitals must decide if they should move these procedures to outpatient-only and receive a decrease in reimbursement. With total hip replacement likely a target for next year, discuss what happens when procedures come off the IPO.
- Outline transitions in practice that must take place when a procedure comes off of the inpatient only list and what conversations are necessary with surgeons
- Discuss how to document medical necessity with surgeries and how to write the orders
- Understand how the change in total knee replacement policy impacts the Two Midnight Rule
- Learn the financial impact of these policy changes on the hospital and patient
National Clinical Advisor and Chief Medical Officer
Sound Advisory Services
Advances in data analytics provide a key advantage to improve utilization management practices. The ability to monitor trends and manage populations at great scale lets organizations identify opportunities to create initiatives which proactively handle potential overutilization and underutilization. Health plans that develop a robust analytics capability have a significant advantage in effectively managing care.
- Use analytics to predict future conditions and treatments for members to ensure the appropriate utilization of care
- Identify health trends amongst your population and develop strategies to head off future overutilization/underutilization trends
- Leverage social determinants of health to target members with higher risk of readmissions and assign case managers
Medical Senior Director, Enterprise Utilization Management
Many health plans recognize that practicing higher quality – demonstrated through higher HEDIS scores and Star ratings – tend to result in a reduction of the highest drivers of cost such as readmissions and extended lengths of stay. With this in mind, payers are integrating their utilization management, case management, and quality teams in order to achieve the best outcomes possible. By growing collaboration internally between teams, health plans will achieve their fiscal and quality goals.
- Develop strategies by using UM tools and HEDIS data to improve quality of care measures
- Development of cross-functional teams, including pharmacy to improve preventive services and management of high use patients
- Engage with medical directors to lead internal QI efforts and for provider engagement to improve quality measures and patient satisfaction
Appeals and grievances have a direct impact on quality ratings. The challenge comes in predicting what decisions may be appealed and furthermore what may be overturned by an Independent Review Entity such as Maximus. Overturned decisions by IREs result in a negative impact on Star ratings. Utilization Management teams can combat against the overturning of appeals by a thorough examination of historical data and apply lessons learned.
- Use data on past overturns to determine trends that are causing the appeals in the first place
- Discuss known criteria used by IREs for overturning decisions
Transitions of care from inpatient to post-acute services represent a turning point in the care continuum for members. Discharge planning should occur early during the inpatient admission to ensure that discharge is appropriate. An inappropriate discharge to home health of transferring a member to a poor performing SNF can lead to acute inpatient readmissions. A preferred network of post-acute care services and organizations can limit the potential for high cost drivers and readmissions.
- Determine the best performing post-acute care services based on quality criteria in order to develop the preferred network
- Advise provider partners of post-acute preferred network options to encourage utilization over non-performing organizations
- Leverage prior authorization to guide providers to use the preferred network
- Measure outcomes by provider
Vice President, Health Care Services
Genetic testing and counseling is one of the newest waves of preventive services that has the potential to significantly impact utilization. Not only does the new technology pose challenges in it of itself when it comes to questions around utilization, but the results can lead to even more utilization based on what is found.
- Identify current trends of genetic screening and testing services
- Determine the appropriate utilization management approaches to genetic testing
- Identify an appropriate network of providers to ensure in-network usage
Changes to regulations from CMS and accreditation guidelines from organizations such as NCQA and URAC require health plans to remain nimble when it comes to their internal utilization review processes. Payers who adopt strategies to allow for these fluctuations position themselves better to keep their accreditation and remain federally compliant.
- Examine the changes made to NCQA and URAC accreditation guidelines and their impact on UM processes
- Discuss best practices to maintain compliance with CMS amid the changing landscape
- Work with internal teams to communicate changes and determine organizational response
- Identify the amount of time needed and steps devoted to preparation for an ALJ Hearing
- Participate in a “mock” hearing based on a case example provided
The Health Law Partners, P.C.
The Health Law Partners, P.C.
Retired Administrative Law Judge
Office of Medicare Hearings & Appeals (joining remotely)