Download to read offline
More Related Content
Similar to Training medical policy program final version 3
Training medical policy program final version 3
- 1. Introduction to UCare’s MedicalPolicy Program •Why We Need Medical Policies •What is Medical Policy? •Overall Strategy •What is Next? •Who to Contact 11/15/2013 1
- 2. Why Do WeNeed 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: 11/15/2013 2
- 3. What is MedicalPolicy? • 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 11/15/2013 3
- 4. Medical Policy &Coverage Determination Legislative Mandates (DHS, CMS) Medical Policy Medical Director Decision EOC, COC, Contract Clinical Practice Guidelines Member Eligibility InterQual 11/15/2013 4
- 5. 5 Phase 1: Development and Publication Phase2: 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 11/15/2013 5
- 6. QIACC P&T Quality Improvement & Credentialing Council Pharmacy and Therapeutics Council IMPC InterimMedical Policy Committee Implementation Workgroup 11/15/2013 6
- 7. Complexities of Developmentand Implementation Medical Directors Payment Policy Government Relations Clinical Services Coding PEC Claims Information Systems Provider Relations & Contracting Customer Services Marketing Health Care Economics 11/15/2013 Pharmacy Product 7
- 8. Approved Policies: • MyUCare/Resources:/MedicalPolicy 11/15/2013 8
- 9. 2013 Plan: 2014: Continuedimplementation, new policy development, and policy approval 11/15/2013 9
- 10. External Publication: Providers ExternalMedical Policy site ▫ 11/15/2013 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. 10
- 11. 11 11/15/2013 External Publication: Members ExternalMedical Policy Site 11
- 12. What is NextAfter 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 11/15/2013 Phase 2: Implementation Integration, publication, systems, products, operationalize Phase 3: Post-Implementation Utilization, effectiveness, maintenance, feedback 12
- 13. Who to Contactwith 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 11/15/2013 13
Editor's Notes
- #2 - WelcomeJohn Corlett publicationImplementationNot yet completed all elements of implementation
- #4 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
- #5 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
- #7 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
- #8 - 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.
- #9 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.
- #11 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.
- #13 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.
- #14 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