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Training medical policy program final version 3
1. Introduction to UCare’s
Medical Policy Program
•Why We Need Medical Policies
•What is Medical Policy?
•Overall Strategy
•What is Next?
•Who to Contact
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2. 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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3. 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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4. Medical Policy & Coverage Determination
Legislative
Mandates
(DHS, CMS)
Medical
Policy
Medical
Director
Decision
EOC, COC,
Contract
Clinical
Practice
Guidelines
Member
Eligibility
InterQual
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5. 5
Phase 1:
Development and
Publication
Phase 2:
Phase 3:
Implementation
Post-Implementation
•Medical policy topic
identified
•Medical Policy topic
prioritized
•Review of literature
and clinical evidence
•Medical policy
drafted
•IMPC
discussion/approval
•QIACC or P&T
Council
discussion/final
approval
•Clarification and
integration with
payment policy
•Integration into
systems and
processes
•Internal operational
use of medical
policies
•Measure the
utilization,
effectiveness and
outcomes
•Maintenance of
medical policies
•Collect feedback
•Continued
publication
•Initial publication
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7. Complexities of Development and
Implementation
Medical Directors
Payment Policy
Government Relations
Clinical Services
Coding
PEC
Claims
Information Systems
Provider Relations & Contracting
Customer Services
Marketing
Health Care Economics
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Pharmacy
Product
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10. External Publication: Providers
External Medical Policy site
▫
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Medical Policies published for our members and providers on ucare.org are different from our
internal medical policies in that the do not include internal operations instructions, or cost
analysis information.
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12. What is Next After Publication?
▫ Integration with:
Payment policy
Benefit design
Products
Provider Network
Systems
▫ Measurement
▫ Outcomes
Phase 1:
Development/
Publication
Development and final
approval of a medical policy
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Phase 2:
Implementation
Integration, publication,
systems, products,
operationalize
Phase 3:
Post-Implementation
Utilization, effectiveness,
maintenance, feedback
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13. 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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Editor's Notes
- WelcomeJohn Corlett publicationImplementationNot yet completed all elements of implementation
Codes listed in the policies are:may or may not be extensive to explain relevant codes to topics being discussed, but do not fully address all of the nuances needed for claim and payment adjudication. for referencenot superseding specific CMS/DHS guidance
Medical Policies do not supersede what we’ve done with the decision making sequence, all of that is unchangedMedical Policy is a component that will help review cases after other resources have been used if there is no other guidance.- Work that has not been done yet – authorizations, PEC set up
IMPC oversees medical policy development and implementation P& T assists in the management of drug benefitsQIACC provides guidance on the quality of care and approves medical policiesImplementation Workgroup integrates policies within current systems and processes, publishes approved MPs externally and internally
- Implementation kicked off this past spring and summer with John Corlett’s PM assistance.- The implementation workgroup identified steps needed to implement a policy.Policies are at different stages of the processThe more we’ve described the process, the reality is the complexities, it touches different areas, many groups involved, building a number of processes to address this.At this point, because much of this still has to be developed, it is not in place. But we are building a great understanding of what it will take to get policies implemented. We think this will be beneficial in a number of ways, consistency.
These are for internal use, and are the full policy.Internal versions will evolve over the next 6-12 months as we add payment policy and other operational elements of our operation.Only approved policies, they may or may not be implemented yetRollout just starting – will notify when you have access to these in the next week or so- Going forward these will be updated as new policies get approved.
Available to providers, members, and consumersDisclaimer that states these are for informational purposes only and do not constitute medical advice, authorization, payment, or explanation of benefits. Does not guarantee any results or outcomes- Internal staff should direct providers here, if you send or fax policies use the external version.
Implementation workgroup has started to build structure, using a form to trackImplications to benefit design, products, our network. Affects a number of areas.1st phase development, 2nd implementation, 3rd, evaluation/measurement- Third phase is very critical because we want to determine how effective our program is.
We are going to be producing a Lectora version of this presentation for new employees or if you want to review this presentation at a later date. Periodic updates and new policies will be posted on Myucare
