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eviCore Imaging Management and Enhanced Musculoskeletal Review OEBB April 4, 2017 2
History • Today Moda partners with AIM to prior authorize Advanced Imaging services. • Effective April 1, Moda began utilizing eviCore Health to provide prior authorization services. 3
Moda and eviCore partnership Beginning April 1st, Moda Health is engaging eviCore Health to perform prior authorization. eviCore is available to perform prior authorization for the following services: Ultrasounds Advanced Imaging (AI) are not Radiology currently Cardiology subject to prior Ultrasound – OB & Non ‐ OB authorization Musculoskeletal (MSK) for OEBB. This Spine & Joint Surgery will take effect Interventional Pain 10/01/2017. Physical Therapy, Occupational Therapy, Speech Therapy Alternative Care – Chiropractic and Acupuncture 4
Why is Prior Authorization Important? − In times of rapidly rising health care costs, Moda Health strives to offer groups and members quality at an affordable price point. Performing prior authorization review, which focuses health care dollars on services that meet evidence based criteria, is one approach to maintaining affordable premiums. − Impact on OEBB’s premiums ◦ By approving Moda to move forward with an enhanced care management program allowing for a more rigorous approach to advanced imaging and musculoskeletal services focused on prior authorization, OEBB reduced its premiums by 0.85%. This equates to approximately $5 million annually. 5
Why eviCore? • eviCore offers expertise in a broader array of services than Moda’s previous vendor • Familiarity with the Oregon market − eviCore is currently provides the set of PA services offered to Moda customers to other health plans in Oregon. − Providers are familiar with their systems and processes, thus minimizing member and provider impact ◦ Prior Authorizations for Alternative Care and Therapies are new to Moda but they are not new to the Oregon market − eviCore has met with the OIC and Oregon professional societies as it has implemented programs with other health plans. • NCQA/URAC Accredited • eviCore’s criteria is aligned with professional societies governing the services it specializes in. 6
The Moda/eviCore Relationship • Moda’s implementation of the eviCore programs is unique to Moda and is highly customized based on the needs of our members. Many decisions have been made that are specific to Moda • Call response time • Call response time • Medical necessity determination turnaround times • Medical necessity determination turnaround times • System availability • System availability Service Level • No financial incentive to deny care • No financial incentive to deny care Guarantees • Moda will continue to process claims internally • Moda will continue to process claims internally Claims Processing • Customized number of visits approved during ‘registration/notification’ • Customized number of visits approved during ‘registration/notification’ • Therapies reviewed/approved at visit level, not unit level • Therapies reviewed/approved at visit level, not unit level Programs 7
The Moda/eviCore Relationship • eviCore will be held accountable financially to service levels for the following metrics: ◦ Average Speed of Answer (30 seconds or less) ◦ Abandonment Rate (3% or less) ◦ Standard Med Nec TAT (3 business days) ◦ Urgent Med Nec TAT (lesser of 2 business days or 72 hours)) ◦ System Availability (available 7am to 7 pm PST 99% of the time) Fax and Web requests are available 24/7 − Moda will review regular reporting of these metrics and holding both formal and informal meetings with eviCore Account Service Management. Financial penalties apply when service levels are not met. 8
Provider communication • Initial Outreach – January 2017 − Top 25 impacted contracted providers were personally notified with feedback requested − Letter sent to impacted contracted providers notifying them of the upcoming change. It included information related to checking Benefit Tracker (EBT) for member impact based on their employer. • Detailed Communication ‐ February – March 2017 − Meeting held with key Therapy providers (2/6/17) ◦ Multiple follow up conversations are being held to discuss value based contracting and options for delegation of prior authorization. − Meeting held with acupuncturists and lobbyist (3/20/17) ◦ Communicated Moda’s unique relationship with eviCore ◦ Listened to their concerns/suggestions. Will evaluate suggested modifications to processes. − Follow up letter from eviCore to all providers of impacted services (mailed 2/20/2017) − Service ‐ specific training webinars held March 6 – April 6 th . − Personalized on ‐ site training has been offered to key providers of services. − Third letter, including implementation detail, mailed 3/27. 9
OEBB Member communication • Communication sent in March based on utilization within the last 12 months for the following services: − Advanced Imaging Therapies (physical therapy, occupational therapy, speech therapy) − Acupuncture − Chiropractic • Letters mailed to all members who used a out ‐ of ‐ network providers • Email notification sent to all subscribers with valid email on file who used in ‐ network and/or out ‐ of ‐ network providers • Letters mailed to all members who used in ‐ network providers and did not have a valid email address on file with Moda 10
Appendix 11
Services grid The grid below summarizes prior authorization services today compared to a scenario where eviCore is engaged to provide services. Note: Ultrasound section does not apply to OEBB members until 10/1/2017. 12
Services grid continued 13
eviCore alignment with Professional Societies • eviCore is aligned with professional societies of the specialties it offers programs in: − American Academy of Neurology − American College of Rheumatology − American Association of Neurological Surgeons − American Academy of Orthopedic Surgeons − American Society of Interventional Pain Physicians − American Pain Society − Medicare Guidelines − American Physical Therapy Association − American Chiropractic Association − American Speech Language Hearing Association 14
Radiology & Cardiology Solutions Flexible Managing care for 65M (Rad) Commercial, Medicaid, Local and national pricing model & 46M (Card) Members and Medicare programs 15
Inappropriate Imaging & How to Fix It Inappropriate imaging costs the system $3B & $1B annually Self ‐ referrals Medical legal concerns – defensive imaging Communication barriers Provider Drivers of Inappropriate unfamiliarity with Imaging clinical evidence Repeat imaging eviCore’s cost & quality medical benefits management solutions ensure that patients receive the right care at the right time http://www.radiologybusiness.com/topics/healthcare ‐ economics/rsna ‐ 2016 ‐ reasons ‐ wasteful ‐ imaging ‐ %E2%80%94and ‐ how ‐ fix ‐ them 16
Incidental Findings Study Our Radiology solution improves patient safety through the reduction of unnecessary and harmful downstream procedures Chest CT scans yield Nearly 10% of brain incidental findings 19% MRIs result in of the time 19% incidental findings 10% Unnecessary MRIs and CT scans lead Lumbar ‐ spine CT to unnecessary scans have a 40.5% MRIs of the lumbar surgeries, radiation, rate of incidental spine have an 8.4% tests, and findings incidental findings procedures rate 41% 8% Between 40% and 70% CT colonography scans, to of CT scans of the screen for colon cancer, abdomen turn up have a 63% incidental incidental findings 40 ‐ 63% findings rate 70% http://www.wsj.com/articles/when ‐ a ‐ medical ‐ test ‐ leads ‐ to ‐ another ‐ and ‐ another ‐ 1472494983 Sources: Radiology; Canadian Association of Radiologists Journal; American Journal of Roentgenology; Dr. Stella Kang, NYU Langone Medical Center 17
• Advanced imaging services • CT, CTA • MRI, MRA • PET, PET/CT • Nuclear Medicine Radiology Solution • Primary imaging services Covered Services • OB Ultrasound • Non ‐ OB Ultrasound 18
• Advanced imaging and diagnostic services • Stress Testing - Myocardial Perfusion Imaging (SPECT & PET) Stress Echocardiography - • Cardiac CT & MRI • Echocardiography; Transthoracic, Cardiology Solution Transesophageal • Diagnostic Heart Catheterization Covered Services • Implantable Device Services - Pacemakers - Implantable Cardioverter ‐ Defibrillator 19
Musculoskeletal Solution Managing care for Commercial, Medicaid, National & local Flexible pricing & 34M members and Medicare payment integrity programs 20
Musculoskeletal by the Numbers 44 66 Musculoskeletal Musculoskeletal ‐ trained physicians on staff nurses on staff 43 34 Musculoskeletal Million lives therapists covered (PT/OT/ST/MT/CHIRO/ACU) 21
• Spine Surgery Fusions • • Decompressions • Disc replacements • Large Joint Surgery • Joint replacement Arthroscopy • • Open procedures • Interventional Pain Musculoskeletal • Spinal injections Solution Covered Services • Spinal denervations Stimulators/pain pumps • • Specialized Therapy Management • Physical / Occupational / Speech Therapy • Chiropractic / Acupuncture / Massage • Implant Management Claims Review • • Utilization Management 22
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